It Hurts: The Patient with Noncancer Pain
The patient’s pain started on an otherwise normal day—another day of hard work as a certified nurse assistant who frequently did more physically demanding work than she should. She awoke with excruciating pain in her back. When she called her family physician, she was told that she didn’t need to be seen, that she just needed to rest and use NSAIDs for a day or so.
Fast forward a few years. The patient, still in the same job, injures her back again, overexerting herself at work. This time, the pain doesn’t go away. The patient is seen by multiple physicians, none of whom alleviate the pain to the patient’s satisfaction, despite ever-increasing doses of opioids.
Does this patient seem familiar to you? She represents your patient in the emergency room, who hears the nurse say quietly, “There’s another drug seeker in bed two.” Or, he is the patient in the exam room who digs in his heels and insists that he has to take multiple doses of Vicodin just to get through the day. Or, she is the customer in the pharmacy being lectured about the dangers of addiction to narcotics. Treating the patient with chronic pain can be difficult, frustrating, and even dangerous—not only to the patient, but also to you.
Facts and Figures
Twenty percent of the general population is significantly affected by chronic nonmalignant pain (CNMP).1 According to Doris K. Cope, MD, a member of the American Society of Anesthesiologists’ Committee on Pain Medicine, the most common types of chronic pain include headaches, back pain, and joint pain.2
Patients want relief from pain while physicians are often concerned about longer-term issues concerning opioid abuse. Patients with untreated pain may feel that the physicians they consult are unfeeling, paternalistic, judgmental gatekeepers, while physicians must be alert to patients with a high potential for substance addiction. In addition, physicians deal with feedback from pharmacists about over-prescribing, pressure from reimbursement channels to hold down costs, bad experiences with other opioid patients, and the knowledge that some of their colleagues have been punished by state medical boards and even indicted for prescribing opiates.
Opioid Use Is Skyrocketing
In the past 10 years in the U.S., prescriptions for hydrocodone and Oxycontin have increased by approximately 300 percent, while the number of opioid-related deaths has increased fourfold. There are tragic reports of iatrogenic inpatient opioid-related deaths from opioid analgesics. Opioids are now number one on the list of drugs implicated in medical malpractice litigation.3
Physicians who treat acute and chronic pain need to be comfortable and secure in their competency. Physicians need to be cognizant of correct dosing guidelines, which may have dramatically changed in the past decade. For example, current dosing recommendations for Dilaudid are much lower than previous recommendations. Before prescribing opioids, physicians need to obtain a patient’s history of any substance and alcohol abuse, his or her psychiatric history for anxiety or depression, and any comorbidities, such as obstructive sleep apnea.
In response to the dramatic increase in opioid use and the fallout complications, the U.S. Food and Drug Administration (FDA), state medical boards, and professional associations are developing regulations and guidelines for the safe and effective use of opioids. Here are a few examples:
- The FDA is developing a Risk Evaluation and Mitigation Strategies (REMS) program for the use of long-acting and extended-release opioids. These continuing medical education (CME) programs will be voluntary and funded by the manufacturers of opioids.4
- The California Society of Anesthesiologists provides online CME programs on pain management and end-of-life care that includes preventive measures to help reduce the practitioner’s risk of becoming involved in a medical-legal action.5
- Legislatures have mandated regulations by state medical boards.
- Online real-time access to drug-monitoring databases that contain patient prescription history is available in some states so that physicians can evaluate for doctor shopping and have a complete prescription history.
- Urine drug testing for patients on chronic opioids to evaluate compliance and make certain the patient is not abusing synergistic drugs is becoming the standard of care.
We need to adequately treat acute and chronic noncancer pain, protect patients from the unintended consequences of opioids, and ensure patient compliance. Because narcotic prescriptions are aggressively monitored by multiple agencies, physicians may worry that prescribing narcotics can cost them their license.
The Medical Board of California, which provides guidelines for prescribing controlled substances for pain, assures California physicians and surgeons that they need not fear disciplinary or other actions for merely prescribing opioids in the course of treatment of a person for intractable pain. The appropriate use of opioids has been recognized in the California Intractable Pain Treatment Act (Section 2241.5[c] of the California Business and Professions Code). The board expects physicians and surgeons to follow the standard of care in managing pain patients.6
- All patients deserve to be thoroughly assessed for pain and to have their pain managed appropriately to increase the quality of life.
- Noncancer pain is a common and frequently debilitating experience for many patients.
- Because of the risk for misuse and/or abuse of opiate agents, patients with chronic pain should be evaluated and supported according to their level of risk.
- Pain patients need to be listened to, receive validation of symptoms, have their fears calmed, be treated with respect and belief, and have a medical partner for dealing with their pain.
- Understand the risks and barriers to effective pain management.
- Prescribe only to your patients.
- Educate and provide informed consent and/or use patient-provider prescription agreements.
- Document—use a flow sheet to help monitor prescription refills.
- Utilize pain management specialists in your community whose practices are designed to manage and monitor chronic pain patients.
- Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well-being: a World Health Organization Study in Primary Care. JAMA. 1998 Jul 8;280(2):147-151.
- American Society of Anesthesiologists. Anesthesia Topics. Q&A: Chronic pain. LifeLine to Modern Medicine. http://www.lifelinetomodernmedicine.com/Anesthesia-Topics/QA-Chronic-Pain.aspx. Accessed September 4, 2012.
- Boyer EW. Management of opioid analgesic overdose. NEJM. 2012;367(2):146-155.
- Nelson LS, Perrone J. Curbing the opioid epidemic in the United States: The risk evaluation and mitigation strategy (REMS). JAMA. 2012;308(5):457-458.
- California Society of Anesthesiologists. Online CME Program page. Available at: www.csahq.org/cme2/course.php?course=3. Accessed March 20, 2008.
- Guidelines for prescribing controlled substances for pain. Medical Board of California Web site. www.medbd.ca.gov/pain_guidelines.html.
By Susan Shepard, MSN, RN, Director, Patient Safety Education. Updated by Howard Marcus, MD, FACP, Chair, Texas Alliance for Patient Access, and Chairman, The Doctors Company Texas Physician Advisory Board.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.