Prescription Opioids and Pain Management: The Tennessee Guidelines _ ______________________________
CHRONIC NON-MALIGNANT PAIN Chronic pain is defined as unremitting or daily recurring pain lasting more than three months. The management of chronic pain is among the most prevalent and vexing of clinical issues, a challenge common to physicians and nurses in every clinical discipline of care. As a matter of public health importance, approximately one in five adults in the United States suffered from some form of chronic pain in 2019, many of whom reported “high impact” chronic pain defined as having pain on most days or every day for the past three months that limited life or work activities [10]. Nonpharmacologic therapy and non-opioid pharmacologic therapy are the preferred first- line therapies for chronic pain. If opioids are required, they should be combined with nonpharmacologic therapy and/or non-opioid pharmacologic therapy, as appropriate. Clinicians should consider opioid therapy only if expected benefits for pain and function are anticipated to outweigh risks to the patient [10]. Healthcare professionals are obligated to know and apply best practice principles to the use of prescription opioids for management of chronic pain, including knowledge of opioid prescription drug selection and dosage, the associated risks of opioids, approaches to the assessment of pain and function, and appropriate pain management modalities. Pharmacologic and nonpharmacologic approaches should be used on the basis of current knowledge in the evidence base or best clinical practices. Patients with moderate-to-severe chronic pain who have been assessed and treated with an adequate trial of non- opioid therapy or nonpharmacologic pain therapy, without satisfactory pain relief, are considered to be candidates for a trial of opioid therapy [9; 10]. Initial treatment should always be considered individually determined and as a trial of therapy, not a definitive course of treatment [11].
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 psychosocial 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 cancer pain management, with addiction, tolerance, side effects, and regulations being the most important concerns [27; 34; 37; 39; 40; 41]. 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 [37; 39; 41; 42]. As a result, many clinicians, especially primary care physicians, do not feel confident about their ability to manage pain in their patients [37; 39]. Clinicians require a clear understanding of available medications 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 [30; 34; 43; 44]. Morphine, buprenorphine, oxycodone, hydromorphone, fentanyl, and methadone are the most widely used in the United States [45]. Unlike non-opioids, opioids do not have a ceiling effect, and the dose can be titrated until pain is relieved or side effects become unmanageable. For an opioid-naïve patient or a patient who has 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. More than one route of opioid administration will be needed by many patients during end-of-life care, but in general, opioids should be given orally, as this route is the most convenient and least expensive. The transdermal route is preferred to the parenteral route, although dosing with a transdermal patch is less flexible and so may not be appropriate for patients with unstable pain [34]. Intramuscular injections should be avoided because injections are painful, drug absorption is unreliable, and the time to peak concentration is long [34].
CREATING A TREATMENT PLAN AND ASSESSMENT OF ADDICTION RISK
PRIOR TO INITIATING OPIOID THERAPY The Tennessee Chronic Pain Guidelines enumerate several key principles to follow when initiating opioid therapy [94]. Practitioners should bear in mind that prior opioid therapy alone is not sufficient reason to continue opioids, and reasonable non-opioid treatments should be tried first. The prescriber must also assess the patient’s risk for abuse, diversion, and addiction by such means as medical history, validated assessment tool, and state-controlled substance monitoring database. When prescription opioids are considered for women of childbearing age, providers should educate the patient about the risks of opioid use during pregnancy, including the risk of physical dependence and withdrawal in the newborn; upon initiation of opioid therapy, the provider should recommend reliable contraception. A urine drug test (UDT) should be performed before initiating any opioid or benzodiazepine
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