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11 Articles in Volume 6, Issue #5
Clinical Pearls for Treating Headache Patients
Determining Which Low Level Laser to Use
Guidelines for Opioid Management of Pain
Interventional Therapies in the Continuum of Care
Lessons Learned from a Headache TMD Study
Potential Hazards of Vertebroplasty
Splenius Capitis Muscle Syndrome
The Moral Community of the Clinical Pain Medicine Encounter
Urine Drug Testing and Monitoring in Pain Management
Vitamin D Deficiencies in Pain Patients
Why Electromedicine?

Guidelines for Opioid Management of Pain

Guest Editorial from July/August 2006
Editor's Note: One of the goals of the National Foundation for the Treatment of Pain, of which this author is Executive Director, is to improve the clinical care of pain patients. Dr. Hochman wrote an essay, "Essential Considerations in the Treatment of Chronic Pain" that was aimed at that objective. This article is intended to elaborate and expand upon the principles cited in that essay. A major issue in pain management concerns the “Standard of Care.” In some communities, opioids are still demonized as “addictive” and those who desperately need them as “drug-seekers.” In other communities, titration to effectiveness is standard, as in any pharmacotherapy. The objective of this article is to propose a standard approach to pain management, based upon rationality and evidence, as a Community Standard of Care—removed from mythology and politics.

The construction of these proposed guidelines has been a dynamic process. With over 100 physician-specialists involved in the process— through the “Project on Pain and Chemical Dependency”—many drafts and revisions have occurred. The following version has been accepted by all participants with the knowledge that changes may be made in the future, as thinking and analysis evolves. The “LIST,” as this ongoing process is known, was begun by Dr. Russell Portenoy more than 20 years ago and brings together physicians and others vitally concerned with pain management. The members of this project feel strongly that the proposed principles provides enormous advantages over previous efforts, as it puts emphasis on “defining what is right, not what is wrong.”

The guidelines provide clear and unambiguous guidance in the treatment of intractable pain. They establish the Standard of Care for practitioners very specifically, so that there can be no confusion or uncertainty about the proper and effective care of intractable pain patients. They clearly establish the goals of intractable pain treatment and objective means of measuring clinical needs and accomplishments. They eliminate the ambiguities that have created a devastating chill of physicians, causing them to cease treating pain patients out of anxiety and perceived vulnerability. At the same, they assist law enforcement by clearly delineating proper practices and promote rational and evidence-based medicine.

Proposed Opioid Guidelines

  1. In using opioids, standard pharmacological principles shall be followed.
    • The drug initially selected shall be chosen following the WHO guidelines as to a “ladder” approach, starting with an appropriate opioid and moving upwards on the list of available drugs based entirely upon clinical success in controlling the pain being treated. The choice of initial drug should be based solely upon the need of the patient, experience of the physician, sound pharmacologic principles, and, where necessary, cost. The dose and schedule of the drug shall be titrated upwards, following reasonable rates of increase, with careful monitoring for complications and adverse effects, and noting same in the clinical record. Any increase successfully tolerated by the patient shall be considered reasonable. Similarly, any regimen tolerated by the patient with successful outcome in controlling the pain shall be considered reasonable.
    • Adverse effects and complications shall be noted in the record, and utilized in deciding changes in drugs, additions of drugs, or modification of doses or schedules of dosing.
  2. Standard pharmacological resources (such as the Physicians Desk Reference) should be utilized in the choice of initial doses and schedules. But substantial variations occur in patient responses to various drugs and in patient metabolism of these drugs. These standard resources do not reflect these variations and are not the final word on dosing. But they are useful references and should be utilized in the choice of initial doses and schedules – particularly when the physician lacks substantial experience in adjusting treatment to patient response.
    • As no maximum dose or schedule exists for any opioid medication, the maximum dose or schedule utilized shall be determined only by clinical outcome.
    • Respiratory depression is the principal clinical event that shall be used to determine maximum dose and/or schedule. Patients shall be carefully instructed in observing for this adverse event and in the appropriate actions that should be taken in the event of respiratory depression. Other adverse effects, such as sedation, nausea, itching, and constipation should be managed symptomatically and noted in the record. If adverse effects continue to be severe, and cannot be symptomatically relieved, alternative opioids should be substituted.
    • Physiological dependency shall be carefully explained to patients and distinguished, in writing, from Addictive Disorders. Physiological dependency, in which a syndrome of physiological symptoms occur when the drug is reduced in dose or withdrawn, shall be clearly distinguished from an addiction, in which the compulsive use of a substance, often in escalating doses unauthorized by the physician, continues despite the clearly destructive consequences to the user—physically, legally, functionally, and socially. Patients shall be carefully instructed in this distinction, with clear emphasis that when the use of a drug results in improved functionality and reduced symptoms, it shall not be misidentified as an addiction.
    • Pseudoaddiction, in which the patient seeks additional medication because they have not been prescribed sufficient medication to contain their pain, shall not be misidentified as addiction, and patients suffering this situation shall not be pejoratively labeled as “drug-seeking.”
    • Patients will NOT be misinformed that the use of opioid substances will lead to addiction, as there is no scientifically defensible evidence that this occurs.
    • Patients will not be misinformed that opioids cause organ toxicity or brain damage.
  3. Opioids shall be employed only to relieve pain and suffering in which:
    • A diagnosis has been reliably established, if possible. This can be achieved by the summation of prior medical treatment and medical records; through the consensus of medical specialists; or by the findings of appropriate diagnostics. However, when pain is present and the diagnosis remains elusive or undeterminable because of the limits of current medical knowledge, the physician must believe their patient—unless there is a scientifically defensible basis for concluding that the patient is malingering or reliable evidence emerges that reveals the pain is factitious. Physicians operating in good faith, utilizing these principles, shall not be held legally or professionally responsible for patient duplicity.
    • The pain must be treated by all available modalities— pharmacological, physiatric, psychiatric, psychological, interventional, surgical, adjunctive and alternative, with the choice of priorities and emphasis determined by the physician and patient in collaboration. As new knowledge emerges about the neurophysiology of pain, it will be clinically incorporated as fast as it becomes available. The first priority shall always be to achieve the quickest, most efficient and effective, lasting and helpful, relief possible. Suffering, functional impairment, deterioration and compromise in activities of daily living, all resulting in an unacceptably compromised Quality of Life, are incompatible with the standard of care when treatment alternatives to prevent this are available. An acceptable Quality of Life shall be defined as a Life that any ordinary person would find acceptable.
    • Pain levels will be assessed, based upon a consistent set of written criteria (see Figure 1: Pain Scale) on a regular basis in evaluating the effectiveness of opioid treatment and the goal of treatment will be to contain the pain to a level no higher than 3 or 4, if clinically possible. If pain levels exceed 7–8 on a regular basis, despite an adequate trial as to dose, schedule, and combination of agents, interventional treatment with injections, an opioid pump, or spinal cord stimulator, should be considered and appropriate consultation sought from a qualified specialist. Under no circumstances will recurrent pain levels of 10 be permitted to occur.
  4. Progress in treatment will be assessed on a regular basis, but no less than every three months. A written record of progress in range of motion, activities of daily living, and pain levels will be consistently recorded in the patient’s records. This can be done both by physician notations or patient reporting. Pain control, sufficient to permit progress in vocational activities and financial self-sufficiency, will be accepted as prima facie evidence of the legitimacy and necessity of medical management of pain with opioids. In some patients, illness is so severe that “progress” is not possible. As with the dying, for these patients palliative pain care is completely appropriate and acceptable.
  5. These regulations confirm that legitimate pain patients have an absolute right to treatment adequate to contain their pain at levels acceptable to an ordinary person.
  6. Opiophobia is herewith stated to be the categorical opposition to the use of opioids:
    • which is based upon prejudice with no medically or scientifically defensible basis;
    • and, when it causes the denial of appropriate pain management in the treatment of patients, is professionally unacceptable, inadequate medical care, and incompatible with the Standard of Medical Care.
Last updated on: November 18, 2011
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