Survey (SF-36). While the number of studies about the effect of tai chi on pain is increasing, there is a need for improved methodology, sample size, and long-term assessment for these studies to provide the evidence necessary to be considered an effective treatment (Hall et al., 2017). ● Yoga : Has been found to provide significantly greater reduction in chronic neck pain and functional disability than no treatment or treatment as usual in a review of the literature by Sang-Dol (2016). In one study, fewer sick days were used by participants with back pain when yoga or strength training were performed at least two times per week, indicating a need for improved follow-through Pain management barriers The development of a treatment plan that includes pain management is imperative. All involved members of the client’s healthcare team, including occupational therapy practitioners, should be aware of this plan. Ho (2017) describes a plan that promotes “mutual, collaborative, and shared decision making” (p. 34). Without a clear and comprehensive plan, there can be confusion regarding what expectations a client might have for pain management (Geurts et al., 2017). These misunderstandings can lead to a distrust by both practitioner and client, potential stigmatization, and often client dissatisfaction (Ho, 2017; Zoëga et al., 2015). The treatment plan contains information regarding the therapies, both pharmacologic and nonpharmacologic.
with recommendations for movement-based interventions (Brämberg, Bergström, Jensen, Hagberg, & Kwak, 2017). ● Mindfulness-based stress reduction (MBSR) : A structured 8-week group program originally developed for chronic pain populations, incorporates components such as “sitting meditation, walking meditation, hatha yoga and body scan, a sustained mindfulness practice in which attention is sequentially focused on different parts of the body” (Cramer, Haller, Lauche, & Dobos, 2012, p. 2). There is promising evidence to support the use of MBSR to manage low back pain. Vitoula et al. (2018) completed a review of the literature and found a number of studies with evidence to support the use of MBSR with all clients who present with low back pain. Early development of the treatment plan and goals and regular reviews will provide clear objectives that guide the interventions for the client and the practitioner (Workgroup on the Model 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).
● 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 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.
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.
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