Florida Physician Ebook Continuing Education

About a third of people who misuse opioids get them by prescription from one doctor. 93 Many misused opioids became available in the community because they were left over from prescriptions for acute pain. 94 It is incumbent on the HCP to remember that, although most people who are prescribed opioids for pain do not misuse them, it is possible that some people who visit a medical facility for pain are instead seeking opioids to divert for misuse or illegal sale. Creating Pain Treatment Plans All pain management begins with identifying the cause or causes of pain and the biopsychosocial mechanisms that contribute to its severity and associated disability. 3 An effective treatment plan is built out of a full evaluation to establish diagnosis and emphasizes individualized, patient- centered care. When persistent pain pertains to a specific disease condition or patient population, HCPs are advised to seek out evidence-based practice guidelines that are relevant. 3 The patient’s pain type and previous treatments should be evaluated to see if opioid therapy is likely to be effective. The HCP should consider whether medical comorbidities, such as sleep apnea, may increase risk of respiratory depression, whether other available therapies have better or equal evidence, and whether thorough patient evaluation indicates the patient is likely to adhere to the treatment plan. Treatment plans should be revisited and adjusted frequently to ensure goals are being met and any adverse effects of therapy are addressed. The success of a pain management plan is highly dependent on the therapeutic alliance established between the patient and the HCP. Managing Acute Pain For acute pain, non-opioids may offer effective management and should be utilized preferentially, alone or in combination with opioids (when indicated) to increase pain control and spare opioid doses. 25 Much acute pain is manageable with rest, over-the-counter medications, or a short course of opioids and resolution of the underlying cause (e.g., trauma, surgery, illness). Objective signs of an acute, painful medical condition (e.g., bone fracture or imaging that reveals kidney stones) are examples for when opioids are likely indicated. Prompt management of acute pain is necessary to prevent progression to a chronic state. 25 When opioids are indicated, the therapeutic goal is to prescribe the lowest dose that controls pain for a duration lasting only as long as the acute phase. Leftover pills from acute pain prescriptions may later become a chief source of diverted and misused opioids. A systematic review found that 42% to 71% of opioids obtained by surgical patients went unused. 94 Prescriptions beyond three days are usually unnecessary, 64 while more severe episodes rarely need more than 7-14 days, although there are exceptions. 64,86 Be aware that localities and states may have strict regulations governing maximum duration of prescriptions

for acute pain. In nearly all cases, HCPS should not prescribe ER/LA opioids for acute pain. It is worth considering that long-term opioids typically are not recommended for nonspecific back pain, headaches, or fibromyalgia, if the HCP should see a patient experiencing acute pain flares occurring with these conditions. 23 Be aware also that patients who seek opioids to misuse may utilize emergency departments or urgent care for this purpose. The American College of Emergency Physicians (ACEP) has identified acute low back pain and exacerbations of chronic pain as common presenting complaints in the emergency department and recommends assessing whether nonopioid therapies would be adequate pain treatment, reserving opioids for severe pain that would be unresponsive to other therapies. 95 If opioids are indicated, the ACEP recommends prescribing the lowest practical dose for the shortest duration, considering the patient’s risk for opioid misuse or diversion. 95 Checking the state prescription database ahead of prescribing opioids for acute pain can help ensure the patient is receiving the appropriate quantity of opioids for the pain. 3 If pain from surgery or trauma persists beyond the expected healing period, HCPs should reevaluate the diagnosis and treatment plan. Self-Assessment Question 6 Which percentage of people who misuse opioids get them by prescription from one doctor? The correct answer is c. Rationale : About a third (33%) of people who misuse opioids get them by prescription from one doctor. Assessing the Risk of Transition from Acute to Chronic Pain Most cases of chronic pain begin as acute pain, and evidence suggests that prolonged exposure to pain leads to CNS changes that can transform the experience to a chronic syndrome. 25 Studies suggest that one-third of patients have progressively worsening pain intensity postoperatively, 25 and most research on risk factors for transitioning from acute to chronic pain takes place in surgical settings. Established risk factors include younger age, female gender, catastrophizing, low socioeconomic status, preoperative pain, impaired diffuse noxious inhibitory control, type and duration of surgery, injury to specific nerves, severity of acute pain, and, possibly, prior exposure to radiation therapy and chemotherapy. 25 The high association of pain severity with subsequent chronic pain development boosts the rationale for comprehensive pain assessment and treatment in the perioperative setting. 25 It is clear that psychological factors contribute to the pain experience overall and pose risk for chronicity. Depression after injury is an a. 10% b. 25% c. 33% d. 50%

important predictor associated with reduced odds for recovery. 96 In people recovering from musculoskeletal trauma, catastrophic thinking (a psychological factor that responds to CBT) predicted pain intensity and disability at five-to-eight months post-injury. 37 Psychological interventions, following proper evaluation and diagnosis, can play a central role in reducing disability. When delivered before surgery, psychological interventions are shown to reduce postsurgical pain and opioid use 97,98 and may help prevent progression from acute to chronic pain. A systematic literature review found support for two screening tools that may be useful in helping HCPs predict the likelihood of a transition from acute or subacute to chronic low back pain. 99 These tools are the STarT Back Screening Tool and the Örebro Musculoskeletal Pain Questionnaire, which stratify patients in into low-, medium-, and high-risk categories and were found to be valid, reliable and to have predictive value. Intense widespread pain (especially when it is increasing) and fear avoidance were found to predict the transition to chronic pain. Incorporating one of these tools or evaluating common predictors in acute pain can help HCPs identify patients at risk in order to treat them early or refer them for specialist management to prevent the trajectory to chronic pain. Managing Cancer-Related Pain More than 14 million cancer survivors live in the United States. 3 An estimated 40% of cancer survivors experience persistent pain as a result of treatments such as surgery, chemotherapy, and radiation therapy. 3 All HCPs who treat patients with active cancer or with cancer-related pain should assess for, recognize, and treat pain at every encounter. Remember that the CDC guideline for opioid prescribing affirms the use of opioids when benefits outweigh risks and warns against opioid tapering or discontinuation when opioid use may be warranted, such as in treatment of cancer pain or at the end of life. 73 With cancer-related pain, HCPs are encouraged to look beyond narrow treatment choices and incorporate multimodal treatments in a multidisciplinary treatment plan. 3 Cancer survivors should be evaluated for a recurrence or secondary malignancy with any new or worsening pain symptoms. 86 Managing Pain in Palliative Care and at End of Life Persistent, significant pain is common in patients with a limited prognosis, such as those in hospice and palliative care environments. The goal in palliative care is to keep the patient comfortable. HCPs should assess and address pain at every encounter, using multimodal and multidisciplinary care as part of the care management plan as indicated. 3 In end-of-life care, pain control may be balanced against meaningful priorities the patient may have such as mental alertness and maximal interactions with loved ones.

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