Treatment: General Principles of Chronic Non-Cancer Pain (CNCP)

Resident Editor: Michael Incze, MD, MSEd

Faculty Editor: Scott Steiger, MD

Chronic pain is often part of a complex syndrome that includes other bio-psychosocial factors. A care plan for patients with chronic pain should be documented to cover the following:

• Diagnosis: what specific condition is the patient being treated for
• Treatment goals:  specify ways to maximize patient’s quality of life, functional status, minimize the side effects of pain medication, and target specific functional goals as

identified by the patient in his/her own words.

• Treatment plan: teach patients how to maintain a healthy lifestyle with specific action items addressing proper nutrition, sleep hygiene, regular physical activity and stress reduction techniques; document risk/benefit discussion; outline medication plan; provide follow-up instructions

Consider the “Four Quadrants” Model for Chronic Pain Management 

Medications Start with NSAIDs and APAP, being mindful of contraindications and safe use. Consider topicals such as lidocaine and diclofenac Other medications according to type of pain (neuropathic, inflammatory, spastic, etc) Opiates generally discouraged for chronic non-cancer pain, should only be used as part of comprehensive pain agreement and only after other therapies not effective

Physical Physical therapy Joint injections Exercise Program Podiatry Referral TENS Unit

Complementary   Free Chair Massage at the Wellness Center: 1st and 3rd Thursday of the month at 11am Free Acupuncture (call for days/times): SFHP patients: call your insurance for access HERC Wellness Center - in Bayview Glide Memorial Church: 330 Ellis Southeast Health Center Osher Center for Integrative Medicine (upstairs from the Gen Med Clinic at Mt. Zion). Offers some “scholarships” for free or reduced cost acupuncture, biofeedback, massage, etc  UCSF Pain Clinic offers CBT for chronic pain Yoga Yoga to the People, 16th & Mission Mindfulness Activity Breathing Exercise Relaxation Therapy   Limited evidence suggests cannabis  may be efficacious for chronic neuropathic pain

Cognitive Behavioral   Chronic Pain Groups: Warm handoff to Behavioral Health in Clinic. At RFPC, Refer via Behavioral Health Team Short-term therapy Group classes, Eng & Span Mental Health ACCESS line (all SF): 415-255-3737 Sleep Hygiene Ladies Night: Mission Neighborhood Resource Center, Thurs nights, free. 165 Capp (near 17th street) RAMS Peer Support Wellness Center (Market and 9th, 1282 Market) - cooking, art, and exercise classes, free EDUCATION: refer patients to the American Chronic Pain Association Website www.theacpa.org; chronic pain Facebook groups

New patients: Primum non nocere (“first, do no harm”)

General rules:

• Thoroughly assess cause of pain, treat and refer as appropriate
• No opioids for CNCP at first visit to clinic, and no new opioids at first visit with you as new provider
• Address all four quadrants of pain management
• Trial non-opioid analgesics such as acetaminophen, NSAIDs and topical agents
• Avoid NSAIDs in the elderly and those with co-morbid CKD, liver disease, cardiovascular disease, thrombocytopenia, h/o UGIB, or dyspepsia.
• Start low and titrate up to effect with new medications
• Obtain permission to discuss care with all psychiatric and medical providers
• APEX tip: consider using dotphrases “.painchecklist” or “.opiodchecklist” for helpful reminders
• At RFPC, use the “Pain Assessment” template to help chart encounters for chronic pain.

Set and Document Shared Goals:

• No measures have been demonstrated to predict a good response, set shared goals with patients focusing on functional goals
• ID and document a functional goals and monitor throughout treatment
  • “Work ___ hours weekly, exercise ___ hours weekly…”
• ID and document a pain control goal before initiating opioids
  • e.g. move from a “7” on average to a “4” on analog pain score

Maintenance patients

• Reassess ongoing benefits and adverse effects– just because it used to work, does not mean it still does
• Document pain score and progress to functional goal at every visit (at least q 6 months)
• Document last dose of each medication EVERY visit
• Consider referral to pain clinic if:

• Debilitating symptoms or loss of functioning
• Symptoms located at multiple sites
• Symptoms that do not respond to initial therapies
• Escalating need for pain medication

Treatment: A Word on Opiate Prescribing

There is weak evidence that opioids are effective for chronic non-cancer pain, yet they are commonly prescribed for this indication, with prescriptions for opioids quadrupling between 1997 and 2010.  Concomitant increases in opioid overdose, and opioid use disorder led to a decline in prescriptions and development of national guidelines for safer prescribing practices (Dowell, 2016).

Treatment agreements outlining risks of opioids, urine drug testing, and prescription of naloxone are MANDATORY in all patients on chronic opioid therapy.  Treatment agreements should by updated and signed by provider and patient annually

Risk Assessment for Patients on Chronic Opioids

• Patients on chronic opioids should have utox at minimum every twelve months and PDMP (CURES) every three months as part of treatment agreement
• Concomitant benzodiazepine use is associated with increased risk of overdose and death
• Treatment agreement should be updated and signed by patient and provider annually
• Lost prescription or medication = high risk to community (and patient)

• Frequent toxicology testing
  • Q1mo (at least) for any aberrant behavior, dose above equivalent of morphine 100 mg (http://opioidcalculator.practicalpainmanagement.com/)
  • Q12mo acceptable only in stable, low dose, low risk patient
  • One technique for obtaining screening urine toxicology tests in clinic is to work with the medical assistant (MA): the MA will hold the prescription until the patient provides a urine sample, and if the patient cannot provide a urine sample then s/he cannot receive their prescription for controlled substances.
• Consider occasional pill count visit with RN 1-2 weeks after MD visit; this is especially useful for high dose patients
• Mitigate risks! 
  • Refer/communicate with psychiatrist, social worker, substance abuse treatment
  • Involve family member(s) early and often
• When problems arise (early refill request, lost medication, +utox, increased side effects):
• Increase monitoring
  • More frequent urine toxicology testing
  • More frequent visits
  • Pill count visit
  • Discuss with patient in risk/benefit terms!
• Refer for more help: social work, substance abuse treatment, psych

Tapering: when risks > benefits (aberrant behaviors, intolerable side effects, lack of progression toward therapeutic goals)

• Best evidence suggests tapers only successful when they are voluntary.  Patient engagement = MUCH higher chance of success

• Write EXPLICIT instructions: useful for patients and providers.
• Consider writing weekly prescriptions; drawback may be multiple copays given multiple prescriptions.
• If multiple agents, convert to morphine equivalents to calculate total dose.
• Engage patient preference to decide whether to taper long-acting or short acting opioids first.  If patient defers to you, taper long acting first

Slow taper  (minimizes withdrawal symptoms)

Indications: no evidence of benefit, high doses, multiple high-risk behaviors

• Go slow and consider removing 10% of original dose per month in an incremental fashion
• Consider changing formulation of short-acting opioid to a lower dose formulation and reducing daily dose by 1-2 pills each week
• Can convert long-acting opioid to lower dose formulation as well

Rapid taper 

Indications: extra-medical use, loss of control over pill use

• Remove 10-15% per week
• Use the urine drug screen as an opportunity for counseling on substance use and transition to buprenorphine in primary care versus referral to addiction treatment

Immediate cessation

Indications: overdose, suicide attempt, prescription forgery, diversion, physical assault or threat to provider or staff

• Add flag to patient’s chart and update problem list with explicit reasons

Consider using the following to help manage withdrawal symptoms:

• Clonidine (hypertension, tremors, sweats, anxiety)
• Hydroxyzine or diphenhydramine (anxiety, restlessness, insomnia)
• Phenergan or metoclopramide (nausea)
• Tums, milk of magnesia (dyspepsia)
• Loperamide (loose stool)
• Acetaminophen (pain, fever)

 

Medication	Typical Dosing	Dosing Interval	Max dose q24h	Comments	Adverse Effects
Selected Non-Opioid Analgesics (class)
Acetaminophen	500-1000 mg	4h	4 gm (2 gm if  liver disease)	Consider as 1st line in OA	Liver toxicity at high doses
Ibuprofen (NSAID)	400-800 mg	6h	2400 mg	Especially good for inflammatory conditions, bony pain, consider PPI if mod-high risk GI toxicity, cardiac toxicity	GI upset, GI bleeding, plt dysfunction, nephrotoxicity, cardiac toxicity
Naproxen (NSAID)	500 mg initially, then 250 mg	12h	1500 mg	Same as for Ibuprofen, but likely less cardiac toxicity	Same as for Ibuprofen, except less cardiac toxicity
Celecoxib (NSAID)	100-200 mg	12h	200-400 mg	Doesn’t interfere with platelet aggregation	Risk of cardiovascular events
Tramadol	25-50 mg	4-6h	400 mg (300 mg in elderly)	Has weak affinity for mu receptor	HA, confusion, sedation, nausea
Selected Co-Analgesics (class)
Gabapentin (anticonvulsant)	Titrate q3 days from 100-300 mg qhs	TID	No upper limit	Use for neuropathic pain; Adjust if renal disease; very few drug-drug interactions, minimum effective dose 900 mg total/day	Dizziness, sedation
Duloxetine (SNRI)	30-60 mg	Daily	60 mg	Use for neuropathic pain, also FDA approved for chronic MSK pain. SNRI Venlafaxine has similar effects	Nausea, dry mouth, insomnia, drowsiness, constipation, fatigue, dizziness
Nortriptyline (TCA)	10-75 mg	Daily	300 mg	Effects neuropathic pain at lower doses than for depression (i.e. 1-3 days vs weeks); all TCAs seem effective	Anti-cholinergic side effects (highest with Amitriptyline so would avoid)
Baclofen (Skeletal muscle relaxant)	5-10 mg	TID	120 mg	Helpful for muscle spasm as well as neuropathy; other agents in class include Cyclobenzaprine and Carisoprodol (latter has high abuse potential)	Sedation, dizziness, abuse potential.  Benzodiazepines may be just as effective for spasm.
Lidocaine patch (Local anesthetic)	5% patch applied to area of pain	BID	1-4 patches at a time	Not all insurances cover, also available as a gel or cream; other somewhat effective local anesthetic is Capsaicin cream	Skin irritation, contact dermatitis

 

Opioid (by increasing potency)	Parenteral Route	Oral Route	Starting Dose for Opioid Naive	Breakthrough Pain If using SR opioids ATC, rx IR opioid for breakthrough pain. Breakthrough dose is 10-15% of the 24h total daily opioid dose, available q1-2h.   If using 3 or more rescue doses daily, consider increasing ATC dose.
Oxycodone IR: Oxycodone SR: Oxycontin	N/A	20 mg	5 mg IR, 10 mg SR
Morphine IR: Morphine, Roxanol SR: MS Contin, Kadian	10 mg	30 mg	15 mg for both IR and SR formulations	Opioid Conversions Calculate 24h total opioid dose Convert to desired opioid (equivalent 24h dose) using equianalgesic table to left. Divide 24h dose of new opioid by the number of doses given per day. Reduce calculated dose of new opioid by 25% -50% for incomplete cross-tolerance; titrate up as needed.
Hydromorphone (IR only)	1.5 mg	7.5 mg	2 mg
Fentanyl IR: Actiq SR: Patch	0.1 mg	N/A	25 mcg patch = 50-100 mg oral morphine q24h

 

References

• Dowell, Deborah, et al. “CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016.” JAMA, vol. 315, no. 15, 2016, p. 1624., doi:10.1001/jama.2016.1464.
• Nugent, Shannon M., et al. “The Effects of Cannabis Among Adults With Chronic Pain and an Overview of General Harms.” Annals of Internal Medicine, vol. 167, no. 5, 2017, p. 319., doi:10.7326/m17-0155.
• Krebs, Erin E., et al. “Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain.” JAMA, vol. 319, no. 9, June 2018, p. 872., doi:10.1001/jama.2018.0899.
• Darnall, Beth D., et al. “Patient-Centered Prescription Opioid Tapering in Community Outpatients With Chronic Pain.” JAMA Internal Medicine, 2018, doi:10.1001/jamainternmed.2017.8709.
• Frank, Joseph W., et al. “Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy.” Annals of Internal Medicine, vol. 167, no. 3, Nov. 2017, p. 181., doi:10.7326/m17-0598.
• Arnold R, Weissman DE. Calculating Opioid Dose Conversions, 2nd Edition. Fast Facts and Concepts. July 2005; 36. Available at: http://www.eperc.mcw.edu/fastfact/ff_036.htm.
• Meldrum M. The ladder and the clock: cancer pain and public policy at the end of the twentieth century.  J Pain Symptom Manage 2005; 29(1):41-54.