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13 Articles in Volume 12, Issue #9
PROMPT Challenges PROP’s Petition
PROP Answers Questions Raised About Opioid Label Changes
PROP vs PROMPT: Who Speaks for the Pain Doctor?
PROP’s Petition: PPM’s Editorial Board Weighs in
Assessment of Long-term Outcomes Of Opioid Treatment: How to Set Goals and Objectives
Extracorporeal Shock Wave Therapy: Applications in Pain Medicine—Part One
Neck Pain: Diagnosis And Management
Part Two: Trigeminal Neuralgia: A Closer Look at This Enigmatic and Debilitating Disease
Reducing Musculoskeletal Disorders Through Ergonomics
Risk Evaluation and Mitigation Strategy Compliance
Treating the Opioid-addicted Chronic Pain Patient: The Role of Suboxone
Electromagnetic Devices: A New Partner in Pain Management
Methadone Management in a Patient With Pain and History Of Addiction

Assessment of Long-term Outcomes Of Opioid Treatment: How to Set Goals and Objectives

Provided here are three simple assessments pain practitioners can adopt or modify for use in their own long-term outcome evaluations.

During office visits there is, unfortunately, little time to assess the long-term, therapeutic outcomes of a chronic pain patient treated with opioids. Assessment of long-term outcomes of opioid treatment is a necessity, however, because opioid treatment is controversial, expensive, and long-term data are often missing from the medical literature.

This article defines what is meant by a long-term outcome and provides three practical, easy-to-administer survey instruments to assess some long-term treatment outcomes. The first assessment survey is designed to provide some objective, numerical facts after 30 to 90 days of treatment. If no improvement in treatment is occurring within 90 days, why continue? The second assessment survey is designed to determine whether improvements in physiologic functions—such as walking, sleeping, memory, dressing, and movement—have occurred. The third survey instrument assesses mental outlook and quality of life.

These three assessment instruments can be easily and quickly administered to a patient or family member at any time, and repeated as needed. Feel free to use the survey instruments presented here or modify them for your own clinical situation. You may also find questionnaires or get some ideas from reports on pain treatment assessments that have previously been published.1-3

Long-term Outcome Defined
“A change in physiologic or mental functions and quality-of-life developments that have occurred after 90 or more days of treatment.”

Few assessment instruments are available that are appropriate for measuring 1-year opioid treatment outcomes.1-6 There are some well-known pain evaluation scales, such as the McGill Pain Questionnaire, but they primarily focus on short-term causes and results.4-6 Many of these assessment scales focus on intensity and quality of pain by asking the patient to judge such measures of pain as whether it is intermittent, continuous, nagging, wretched, burning, or causes fatigue.1,3,4-7 While these scales are clinically helpful to determine immediate treatment needs, they do not, in my opinion, assess very well the practical long-term outcomes of opioid treatment.

Setting an Overall Goal and Objectives
A goal is the overall end product of an effort. An objective is a step or achievement along the way.

In treating pain patients who require opioids, the overall goal is to provide enough pain control to allow the patient to leave their bed or couch, carry on activities of daily living such as dressing and eating, and achieve an improved quality of life. Ideally, the goal also would include a cure of pain so that the patient can discard opioids. This is hardly a practical, achievable goal in most patients who require opioids for pain control, since these patients invariably have incurable, permanent neurological damage or injury. Objectives of treatment must be practical accomplishments in achieving the overall goal. They are steps along the treatment course that may be small and simple—such as arranging clinic attendance and identifying a pharmacist. Or they can be major—like ceasing emergency visits or stopping the use of alcohol for self-treatment of pain.

Assessment of treatment success and outcome should have some direct relationship to the overall goal of treatment and objectives that are set at the initiation of treatment or refined during the course of treatment. This is why many state regulations and guidelines as well as the standards set by the Association of State Medical Boards require the physician to establish goals and objectives for opioid treatment.

Here’s a common problem: pain practitioners are highly qualified medical personnel who instinctively and automatically set a goal and objectives for every patient. They intuitively know what they want the patient to accomplish. Unfortunately, the overall treatment goals and objectives with opioid treatment may remain only in the mind of the practitioner and not recorded in a patient’s chart. At least some of the goals and objectives need to be put in writing. Table 1 identifies a sample goal plus a number of possible objectives for opioid treatment of chronic pain. I put a copy of this table in all my patients’ charts, and I give a copy to each patient and family member so they will know what I want them to accomplish. Clinicians should develop a picture of what they want as an overall goal and objectives for their patients and then communicate that to them.

Table 1. Sample Goal and Objectives for Opioid Treatment in a Chronic Pain Patient

Why Assess Long-term Outcomes?
Critics of opioid treatment, regardless of their motive, constantly harp on the fact that there is a lack of long-term outcome studies in opioid treatment. Actually, there are some good studies on opioid treatment outcomes.8,9 Unfortunately, the relative lack of outcome studies has apparently given a negative attitude to some third-party payors, regulators, and plaintiff attorneys. It is, therefore, incumbent on all practitioners who prescribe opioid therapy to assess some long-term outcomes, and make these assessments part of each patient’s permanent record. Keep in mind that today, every patient’s record will likely be reviewed at some point in time by outside parties. The high cost of treatment will likely ensure this trend.

Equally or more importantly than an outside review, the practitioner, patient, and family need to know whether long-term benefits are resulting from opioid treatment. Particularly with the potent opioids, such treatment almost always has complications of which hormonal suppression is the most predictable.8,9 Opioids, in some cases, may possibly produce central nervous system deterioration and immune suppression.8,9 Knowing that these side effects may occur, the question becomes whether opioid treatment is providing benefits that outweigh the risks.

Focus on Improvement of Physiologic Functions and Mental Outlook
Long-term assessment of opioid treatment should focus on patient improvement in physiologic functions and mental outlook. Why? The vast majority of chronic pain patients have permanent, irreversible, and incurable degeneration and deterioration of nerve tissue. We can no more “cure” most cases of chronic pain (particularly in those who may have a legal classification of intractable or palliative pain) than we can cure hypertension, diabetes, or emphysema. We can, however, provide improvement in physiologic functions and mental outlook. “Quality of life” is the new buzzword for happiness and contentment. Patients now frequently voice this phrase. It is our job, consequently, to systematically and periodically assess our treatment to determine whether the patient is achieving an improvement in their quality of life.2,7,8,10

 

Table 2. 30- to 90-day Objective Treatment Assessment

30- to 90-day Assessment
As noted earlier, the first assessment instrument is used in my clinic after a patient has been in treatment for 30 to 90 days (Table 2). I also periodically use it later in treatment. It is designed to determine whether opioid treatment is meeting some specific objectives: Is the initiation of opioid treatment getting some quantifiable results? Since opioid treatment is potentially hazardous, it should be stopped if you aren’t getting positive outcomes within the first 90 days of treatment. Don’t just ask about the pain score; get some facts. Is the patient out of bed, off the couch, and beginning to put together a new life? Can the patient now dress him or herself and leave the house? Note that the sample 30- to 90-day treatment assessment asks the patient for specific numbers and not just opinion.

Table 3. Assessment of Physical Functions.

Physiologic Functions and Mental Outlook
There’s never a bad time in opioid treatment to use a “paper and pencil” assessment tool to find out how the patient is doing. Are we reaching the overall goal of a functional existence, controlled pain, and an improved quality of life? You may find it convenient to assess every patient on a yearly basis. I pick a month and have a stack of assessment instruments at the front desk. No one gets past the receptionist without telling me, in writing, whether their life and opioid treatment are achieving the goal and objectives we outlined. My two favorite assessment instruments are presented here. One is for physiologic functions (Table 3) and the other for mental outlook and quality of life (Table 4).

There are 17 physiologic functions in my assessment survey. Patients state whether they are better, same, or worse than when they started opioid treatment. Included in this assessment are such basic physiologic functions as smell, taste, movement, libido, dressing, reading, memory, and appetite. Severe pain can adversely affect essentially every physiologic function in the body. Table 5 is a recent survey of 40 of my severe intractable pain patients who have been on opioid treatment for more than 10 years. While all 40 patients reported improvement in at least one physiologic function, the majority had improvements in many functions. Few patients claimed to worsen in physiologic functions.

Table 4. Mental Outlook Assessment

Despite its risks, some pain patients will achieve an effective opioid regimen that allows them to survive, thrive, and develop a very happy, productive life. Patients with severe intractable pain invariably enter opioid treatment with an extremely poor mental outlook. They often feel hopeless, suicidal, depressed, and confused. A dramatic change in their mental status may take place while on opioid treatment, and we need to document these mental changes. The 40 patients in our study who have taken opioids for more than 10 years all (100%) stated they were depressed at entry into opioid treatment. About 80% claimed they felt “hopeless.” All later claimed they were neither depressed nor hopeless. The message here is simple: patients, over time, can be assessed for mental outlook relative to quality of life, happiness, hopelessness, and depression. These assessments may be subjective and mean different things to different people, but they can be individually assessed. Our job as practitioners is to make sure that opioids and other therapies help improve a patient’s mental outlook and give each patient an opportunity for happiness and contentment.

Table 5. Improvement in Physiologic Functions After 10 or More Years of Opioid Therapy

Summary
Pain practitioners who prescribe opioids need to periodically administer some long-term outcome assessment instruments to their patients. While we can’t possibly cure the vast majority of chronic pain patients, we can improve many of their physiologic functions and quality of life. It is important to the patient, family, and all other concerned parties to know that opioid treatment is beneficial to a patient. Since chronic opioid therapy often has side effects, particularly hormonal suppression, we must show that benefits of therapy outweigh the risks. Given here are three simple assessment instruments you can adopt or modify for your own needs.

Last updated on: December 22, 2014
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