The Smart Patient's Guide to
Chronic Pain Management

Opioids and Chronic Pain Management: Why It's So Complicated

Practical Pain Management spoke to Theresa Mallick-Searle, NP, a pain specialist at Stanford Health Care in the Division of Pain Management, Stanford University Medical School in California to help you understand the use of opioids—when they're appropriate and when they're not—in the management of pain and to elaborate on their complicated role.

View/download the sample contract  (PDF)

Q. When are opioids the preferred choice for pain?

Opioids are one of many pharmacological options for the management chronic pain. When choosing an opioid as part of the treatment regime, your doctor should weigh the risks with the potential benefits. Rarely are opioids used in isolation, they are generally part of a treatment plan that includes the use of other non-opioid analgesics, behavioral management therapies, physical therapy and possibly interventional therapies. (For more information about non-opioid treatments click here and here.)

There are basically two types of pain—acute and chronic. Acute pain is the predictable response to trauma, injury, surgery. It’s generally short lived, protective, and often responds to short-term opioid treatment.

Chronic pain, on the other hand is pain that persists beyond expected tissue healing (3 months or greater) and is often complicated by some persistent nerve or nervous system injury (such as with post-herpetic neuralgia or spinal cord injury). Chronic or persistent pain is much less responsive to short-term opioids and is controversial for long-term opioid treatment due to side effects and risks of dependency.

The best treatment for chronic pain is a multimodal therapy plan that could include intervention from a physical therapist, pain psychologist, complementary alternative medicine (i.e. acupuncture) and self-management techniques (such as changes to the diet and exercises regimes) to help you not only manage your pain effectively but learn to cope with it.

It's worth noting that chronic pain is associated with much psychological stress, disability and greatly impacts the family and society. A report conducted by the Institute of Medicine to assess the state of the science regarding pain research, care and education estimated a cost of $560-635 billion annually in direct medical treatment costs and lost productivity in the U.S. resulting from chronic pain.

Q. Why is there an opioid use crisis in the US?

Most clinicians and other healthcare providers receive little education around the complexities of managing pain, the potential for opioid abuse and the inherent risks of chronic opioid use. As a result, historically, the management of chronic pain has not been multi-dimensional which is the best approach.

Couple that with the pressure on primary care practitioners to increase the number of patients they see each day and the fact that insurance plans tend to cover opioids over alternative treatment methods, it’s not hard to see how we got here.

Frankly when a patient is in pain, it may be easier and faster to write a prescription than invest the time in counseling, goal setting and problem solving. There are also patient expectations to consider. Many patients come into a practitioner’s office expecting to leave with a prescription, a “quick fix”. 

Q. How does opioid medication work and why is it addictive?

Basically, opioids work by binding to the receptors in the central and peripheral nerve system (mostly in the brain) to activate the release of chemicals, such as dopamine, to reduce pain. Opioids are also thought to act on other areas of the brain (the limbic system) to lessen the emotional impact of pain.

What makes opioids potentially addictive, unlike some of the other medications that we use in pain management (acetaminophen, NSAIDs, antidepressants, anticonvulsants), is that they effect the pleasure centers of the brain and can expose the individual to a sense of wellbeing, euphoria, contentment.

Like with any medication that may be prescribed for pain, the clinician should discuss the risks and benefits of the medication, how the use of an opioid fits into the bigger picture of therapy and safety considerations (such as using only as prescribed, not sharing medication, appropriate disposal, abuse potential, how to safely discontinue, etc.).

Q. How can safe opioid use be encouraged?

COT doctor and patient Singing a treatment agreement with your physician can help you feel confident that your physician is taking your pain seriously.It is not "legally" required for a patient to sign an opioid contract or treatment agreement form when opioids are prescribed but it is strongly recommended. A formally-documented agreement/contract however is becoming standard of care when chronic opioid therapy (COT) is prescribed.

Good practice starts with the development of a formal pain treatment plan that is consistent and includes clear and protective measures for both the patient and the practice:

  1. A documented discussion with the patient about risks, benefits and responsibilities surrounding the taking and prescribing of COT.
  2. A signed “treatment agreement” (a sample can be download from the top of page) outlining the above, can go a long way toward helping you feel your physician is taking your pain seriously and that the two of you are working as partners in finding the best possible treatment. A well-written agreement between physician and patient is not punitive, establishes responsibilities of care and sets out expectations for continuing the plan of prescribing opioids.
  3. Establishing a Risk Evaluation and Mitigation Strategy (REMS) for physicians to use to assist in identifying patients at higher risk for abuse and misuse of opioids helps clarify the degree of monitoring that is required to assure compliance with prescribed therapy (e.g. follow-up visits, prescription refills, UDS, pill counts, etc.).
  4. Documenting the goals of care and compliance with each prescription refill (see the 4 A's below).

A Simple Way to Document Care and Compliance

Adopting the 4 A's is a simple way for the physician to document the goals of care and opioid compliance:

  • Analgesia. Is the patient reporting good pain relief with the treatment?
  • Activities of daily living. Is the patient reporting improvement in the ability to exercise and work? Is the patient self-sufficient with daily tasks (driving, laundry, household chores and personal hygiene)?
  • Adverse effects. Is the patient complaining of nausea, unmanageable constipation, sedation, altered cognition, medication interfering with work or personal relationships?
  • Aberrant drug-taking behaviors. Was a prescription drug monitoring program (PDMP) accessed and consistent with medications as prescribed? Were any emergency department visits reported for opioids or misuse? To measure compliance, a urine drug screening (UDS) should be considered at next visit, or every 6 months.

Thoughts on the Future of Pain Management

I feel that clinicians are still trying to come to terms with what the CDC guidelines mean and how-to responsibility incorporate them into their respective practices. There is much fear and uncertainty about how to prescribe opioids safely, who is the right patient for opioids and how to set up a practice that is accountable for safe opioid prescribing. As a result, many clinicians are either referring patients out of their practices, or pulling back on opioid prescribing altogether.

I also think that patients currently taking opioids for chronic pain should be reassessed by the healthcare provider as to whether or not the current therapy is still appropriate.If so, then a REMS strategy should be put in place to make sure that the patient continues to be safe with his treatment plan. A REMS strategy also gives the healthcare provider and patient an opportunity to also explore non-opioid medication therapies that perhaps were not fully explored in the past.

Updated on: 12/19/19
Continue Reading:
Opioids: Addiction or Physical Dependence?