Policy for the Use of Opioid Anagesics in the Treatment of Chronic Pain [Workgroup], 2017). In April of 2017, the Federation of State Medical Boards of the United States adopted the Guidelines for the Chronic
Use of Opioid Analgesics as a resource for state medical and osteopathic boards (Workgroup, 2017). These guidelines are found in Table 5 and recommend a complete and comprehensive evaluation.
Table 5: Guidelines to Complete Evaluation Biological components ● Medical history and physical examination of targeted pain condition. ● Nature and intensity of the pain.
● Underlying or coexisting diseases or conditions, including those which could complicate treatment (i.e., obesity, renal disease, sleep apnea, chronic obstructive pulmonary disease, etc.). ● Urine, blood, or other types of biological samples and diagnostic markers. ● Effect of pain on physical functioning. ● Effect of pain on psychological functioning. ● Personal and family history of substance use disorder. ● History of psychiatric disorders (bipolar, ADD/ADHD, sociopathic, borderline, major depressive). ● Post-traumatic stress disorder (PTSD). ● Current and past treatments, including interventional treatments, with response to each treatment. ● Medical indication(s) for use of opioids. ● Review of the prescription drug monitoring program results. ● Consultation with other clinicians when applicable.
Psychological components
Interventional components
Note . Adapted from Workgroup on the Model Policy for the Use of Opioid Anagesics in the Treatment of Chronic Pain, 2017. Based on information gathered during the evaluation, the client and clinician together develop a treatment plan and goals. Goals focus on improvement in function and decreasing other symptoms related to pain. It is important to include the pharmacologic and nonpharmacologic interventions, including other diagnostic tests, consultations, or therapies (cognitive behavioral, massage, exercise), that are a consideration (Workgroup, 2017).
pharmacy. Although these behaviors may be perfectly innocent, they could potentially put the therapeutic relationships at risk. Common complaints that may give rise to lower patient satisfaction and potential litigation include inadequate pain control during treatment, side effects of pain treatment, trauma received while under the care of a health professional, practitioner/physician error, and lack of client knowledge or consent (CNA Healthcare, 2017; Makhni et al., 2018; Zoëga et al., 2015). It is important to note that the experience of being in litigation could negatively affect the client’s pain (Tabaraee et al., 2015). Clients with chronic pain can experience stigma not only from their healthcare providers but also from family, friends, and coworkers, who may doubt the legitimacy of their pain experience. These people may consider the pain to be “all in the head” or the result of “hysteria” or a low pain tolerance. Pain diagnoses associated with stigma include low back pain, fibromyalgia, and migraines. Stigma about pain can lead to undertreatment (Collier, 2018; McInnis, McQuaid, Bombay, Matheson, & Anisman, 2015). A systematic review of the literature by Cooper and Nielsen (2017) found that people who use prescription opioids experienced stigma related to their substance use. This study also found that those who were using prescription opioids conveyed a stigma against those who used illicit opioids. It is important not to limit recognition of stigma only to that placed by family, friends, and coworkers. Practitioners need to recognize that their own biases, both conscious and unconscious, may affect treatment (Cooper & Nielsen, 2017). These biases could be related to the client’s personal life choices, culture, appearance, or temperament. Overall, the experience of pain is individual; it is important for healthcare professionals to listen to the client’s experiences and validate the client’s pain in order to establish a strong rapport for therapy.
The guidelines recommend the use of an informed consent and treatment agreement, to be used with clients who have long-term chronic use of opioids in the plan of care (Workgroup, 2017). The informed consent discusses all the risks, prescribing policies, reasons for discontinuation, and education around expectations. The treatment agreement outlines the responsibilities of all involved: ● Treatment goals in terms of pain management, restoration of function, and safety. ● Patient’s responsibility for safe medication use. ● Secure storage and safe disposal. ● Patient’s responsibility to obtain prescribed opioids from only one clinician or practice. ● Patient’s responsibility of getting the prescriptions filled at only one pharmacy. ● Patient’s agreement to periodic drug testing. ● Clinician’s responsibility to be available or to have a covering clinician available to care for unforeseen problems and to prescribe scheduled refills. (Workgroup, 2017) Although this agreement is often between the physician and client, the healthcare professional should be aware of its contents in order to support the client. For example, the practitioner may be the one who hears that the client has lost his or her prescription or is filling a prescription at a different
INTERDISCIPLINARY TEAM APPROACH
There is often confusion between the terms multidisciplinary and interdisciplinary . A multidisciplinary approach can be described as more than one healthcare provider (not necessarily at the same location) treating a client’s pain condition, without necessarily coordinating care or communicating with one another. An interdisciplinary approach involves coordinated interventions among disciplines at the same location in an integrated manner with common goals and ongoing communication (Gatchel, McGeary, McGeary, & Lippe, 2014). In research and practice, these terms are often used interchangeably, and for the sake of
this course, we will use the term interdisciplinary because of the need to move from discipline specific practice to a collaborative focus on common goals (Patel, Hacker, Murks, & Ryan, 2016). Interdisciplinary teams have included physicians, physiatrists, psychologists, physical therapy practitioners, kinesiologists, nurses, pharmacists, dietitians, health and advice workers, fitness workers, cognitive behavioral therapists, chiropractors, rheumatologists, and social workers (Hammer et al., 2016; Hellman, Jensen, Bergström, & Brämberg, 2016; McGeary et al., 2016).
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