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 non-opioid 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. 1 If pain from surgery or trauma persists beyond the expected healing period, HCPs should reevaluate the diagnosis and treatment plan. 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. 22 Studies suggest that one-third of patients have progressively worsening pain intensity postoperatively, 22 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. 22 The high association of pain severity with subsequent chronic pain development boosts the rationale for comprehensive pain assessment and treatment in the perioperative setting. 22 It is clear that psychological factors contribute to the pain experience overall and pose risk for chronicity. Depression after injury is an 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. 34 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. 1 An estimated 40% of cancer survivors experience persistent pain as a result of treatments such as surgery, chemotherapy, and radiation therapy. 1 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. 72 With cancer-related pain, HCPs are encouraged to look beyond narrow treatment choices and incorporate multimodal treatments in a multidisciplinary treatment plan. 1 Cancer survivors should be evaluated for a recurrence or secondary malignancy with any new or worsening pain symptoms. 85
The goals of treatment should be meaningful to the patient and contain measurable outcomes of improvement that include pain relief, functionality, quality of life, and activities of daily living. 20,61,85 Even patients with pain conditions or injuries that make complete cessation of pain unlikely can set goals such as sleeping through most nights, returning to work, walking a set distance, or participating more fully in family activities. The self-efficacy involved in collaborating on these goals can help patients gain greater control over their pain and their lives. Choices in medications are based on pain diagnosis and severity; comorbidities as established through medical history, physical exam, relevant diagnostic procedures; patient response; and a risk-benefit assessment to increase the likelihood that benefits outweigh risks. It is important to differentiate between nociceptive and neuropathic pain and to thoroughly evaluate the patient to aid in an accurate diagnosis, identifying the generator of pain whenever possible. Neuropathic pain can be difficult to manage and generally requires a combination of pharmacologic and nonpharmacologic approaches. 23 Choices of medications for neuropathic pain that provide the most relief include anticonvulsants, antidepressants, or local anesthetics. NSAIDs are not considered effective treatments for neuropathic pain, and opioids should be reserved for patients who did not respond to other therapeutic options. 23,61 For osteoarthritis, ACET and NSAIDs are considered first-line and second-line medications, respectively, and many guidelines recommend NSAIDs and ACET as first-line therapies for low- back pain. 61 Corticosteroid injections are generally recommended for hip and knee osteoarthritis. 101 Expert guidelines usually now recommend against ongoing opioid therapy for nonspecific back pain, headaches, and fibromyalgia. 20 Whenever possible, nonpharmacologic therapies and self-management strategies should be optimized. 27 Noninvasive interventions in specific conditions that have sustained small improvements in pain and function for one month or longer post treatment without serious harms are shown in Table 4. 30 A trial of opioids, when indicated, should be part of a comprehensive treatment approach, typically in combination with one or more treatment modalities. 20 Assessing Pain A patient’s initial visit for evaluation of a pain problem should include a physical exam and a patient interview to gather and document medical history and pain assessment. One should obtain a complete history of current and past substance use and misuse to include prescription drugs, illegal substances, alcohol, and tobacco. Social history is also relevant and includes employment, marital history, and family status. 77 Women should be screened for contraceptive use and pregnancy or breastfeeding status or intent. 61 Previous treatment records, including any pertinent clinical notes of treatments tried, and laboratory and imaging results should be reviewed whenever possible and retained in the current patient record.
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. 1 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. Pain assessment may be challenging in the context of reduced consciousness. Signs of discomfort include more rapid breathing or heart rate. Rectal and transdermal routes can be especially valuable at the end of life when the oral route is precluded because of reduced or absent consciousness, difficulty swallowing, or to avoid nausea and vomiting. 100 Managing Chronic Noncancer Pain To apply best practices in chronic noncancer pain treatment, HCPs should recognize and treat pain promptly, involve patients in the pain care plan, reassess and adjust the pain care plan as needed, monitor patient progress toward treatment goals, monitor patient adherence to any treatment agreements, and document all pain management outcomes in the patient medical record.
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