Active duty military, reserve service members, and veterans Pain management in veterans and active military members can be complex. Combat-related injuries include ballistic wounds, burns, over- pressurization, and blunt trauma. 1 In addition, complications can arise from PTSD and traumatic brain injury. 1 Delaying pain treatment can lead to acute pain becoming chronic. 90 Veterans are also at risk for death by suicide, a risk compounded when pain conditions are present. HCPS can discuss suicide risk with service members and veterans and address pain treatment as part of suicide prevention as a recognized public health approach. 1 Medical complexities of pain care Genetic and phenotypic variations influence how quickly or well different people metabolize opioids and other drugs. 73 Medical conditions, including kidney and liver disease, also cause variations in opioid metabolism. 73 The FDA has approved some tests, for example, one aimed at determining whether a patient is a CYP2D6 ultra- rapid metabolizer. 75 However, little data actually exist to inform the practice of pain management, and these tests are not routinely performed. 91 HPCs should be aware that genetics is one of many factors that may affect drug metabolism and responses, so patient experience with certain pain treatments or medications should be used to develop individualized treatment plans. Definitions Related to Opioid Use and Misuse The HHS Inter-Agency Task Force on best pain management practices endorsed a set of definitions to guide conversations and understanding of frequent terms related to opioid use and misuse. 1 These definitions are shown in Table 3.
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. 22 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. 22 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, 61 while more severe episodes rarely need more than 7-14 days, although there are exceptions. 61,85 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. 20
Diversion
Most people who misuse prescription opioids are given them freely by friends or family members, though some people buy or steal them. 93 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. 1 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. 1 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.
Table 3. Definitions Related to Opioid Use and Misuse 1
Term
Definition
Physical dependence • Not the same as addiction
• Occurs because of physiological adaptations to chronic exposure to opioids • Withdrawal symptoms occur when medicine or opioid is suddenly reduced or stopped or when antagonist is administered • Symptoms can be mild or severe and can usually be managed medically or avoided through slow opioid taper
Tolerance
• Same dose of opioid given repeatedly produces reduced biological response • Higher dose of opioid is necessary to achieve initial level of response • Taking medication in a manner or dose other than as prescribed • Taking someone else’s prescription, even if for a medical complaint like pain
Misuse
• Taking medication to feel euphoria (i.e., to get high) • Nonmedical use of prescription drugs refers to misuse
Addiction
• Primary, chronic medical disease of brain reward, motivation, memory, and related circuitry • Dysfunction in circuits leads to characteristic biological, psychological, social, and spiritual manifestations as individual pathologically pursues reward and/or relief by substance use and other behaviors • Characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and dysfunctional emotional response • Involves cycles of relapse and remission • Without treatment or recovery activities, is progressive and results in disability or premature death
Opioid-use disorder • A problematic pattern of opioid use leading to clinically significant impairment or distress • Defined by 11 criteria in the DSM-5* over a 12-month period • Previously classified as “opioid abuse” or “opioid dependence” in DSM-4 • Severe opioid-use disorder also referred to as “opioid addiction” *DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; 92 diagnostic criteria given later in this activity
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