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
|
Physical
|
Complementary
|
Cognitive Behavioral
|
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
|
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.