Chronic Pain

The patient-provider relationship is built on a shared understanding of a whole-person treatment approach. Patient preferences and values should be heard, understood and used to inform clinical decisions. Providers should carefully consider and ensure patients are aware of the expected benefits, risks, and alternatives to opioids before starting or continuing opioid therapy.

Resources

Motivational Interviewing Steps and Core Skills [PDF - 2.2 MB]

Motivational Interviewing in Managing Pain Exit Disclaimer: You Are Leaving www.ihs.gov  [PDF - 467 MB] — Providers Clinical Support System

Proper patient assessment is essential when deciding whether or not to initiate opioids for pain and if necessary, when determining the specific opioid, dose, and frequency to prescribe, and the duration of the initial prescription and follow-up intervals. Often, patients with a long history of a pain diagnosis and opioid medication therapy are inherited by providers with little to no historical information as to the origin of the injury, imaging, and other pertinent medical history. It is essential to perform a thorough chart review and obtain historical records from specialists and previous primary care providers. Periodic reassessment by obtaining a completely new and thorough pain history with appropriate imaging may help providers and patients to develop and update treatment plans.

A patient's pain score is just one of several measurements of successful chronic pain treatment. "Zero" pain is not realistic, achievable or desirable. Small reductions in pain are considered major successes if they lead to increased function. Realistic functional goals should be set collaboratively between the prescriber and patient and re-visited routinely. Clinicians should strive to find individualized, objective measures for each pain patient. Pain experts recommend a function-based treatment strategy that focuses on restoring some or all of the pain patient’s normal activities.

Functional assessment tools measure essential characteristics associated with in chronic pain populations and allow the patient a medium in which to express critical facts about how intense the pain is, what part of the body it originates, the type of pain, and how it impacts their quality of life. These tools help to monitor the patient's progress and prevent medication misuse.

A functional assessment should be completed at baseline, annually, when considering dose or frequency changes, and when deemed clinically appropriate. The provider should learn what patient-specific activities have been impacted because of chronic pain and then establish weekly or monthly objectives for restoring these activities using a multi-modal treatment approach. In collaboration with the patient, the provider may consider creating a scale where the lowest end is the patient's ability to engage in only one of their normal activities (e.g., sleeping) and the highest end would be the ability to engage in all their activities (e.g., sleeping, eating, working, recreation, etc.).

The table below outlines individual treatment modalities for managing chronic pain.

The continuation or modification of chronic opioid therapy should be contingent on the evaluation of the patient's progress toward treatment objectives and goals. The risk of adverse events, including diversion and overdose, and quality of life should continue to be monitored and considered. Regardless, safe and effective non-opioid and/or non-pharmacologic options should be considered and utilized in a patients' pain management plan based on an individualized assessment considering the diagnosis, access to treatment, and unique needs of the patient.

Consider tapering to lowest effective dose, which may include discontinuation, when:

• Patient requests dosage reduction or discontinuation
• Pain, function, and quality of life are not meaningfully improved
• Patient has been treated with opioids for a prolonged period (e.g., years), and current benefit-harm balance is unclear
• Higher opioid dose is not providing additional benefits
• Provider suspects opioid misuse
• Patient experiences an overdose or other serious event (e.g., hospitalization, injury) or has warning signs for an impending event such as confusion, sedation, or slurred speech
• Patient is prescribed other high-risk medications (e.g., benzodiazepines) or has medical conditions, such as lung disease, sleep apnea, liver disease, kidney disease, gait disturbances, advanced age, etc., that increase risk for adverse outcomes

Opioids should not be rapidly tapered or discontinued suddenly due to risk of significant opioid withdrawal. An individualized care plan should be created with the patient to reduce risk of acute withdrawal, worsened pain syndrome, anxiety, depression, suicidal ideation, self-harm, weakened trust with the health system, and patients seeking opioids from illicit sources.

• Interdisciplinary case management, some examples:
  • Pharmacists may help prescribers manage patient tapers, monitor response, manage withdrawal symptoms, and provide patient education
  • Behavioral health team members may assist with patient education and behavioral strategies surrounding anxiety with an opioid taper
• Documentation of patient education on the risk of overdose with the abrupt return to a previously prescribed higher dose of opioids
• Naloxone should be provided
• Education of harm reduction strategies and available services
• If physical dependence is suspected, the discontinuation of opioid treatment should not mark the end of treatment, but rather, other modalities should be utilized, either through direct care or referral to other health care specialists
• Slow and gradual tapers should help to lessen withdrawal symptoms, and withdrawal should be managed by the provider or pain specialist

Resources

• Clinicians on the Appropriate Dosage Reduction or Discontinue of Long-Term Opioid Analgesics Exit Disclaimer: You Are Leaving www.ihs.gov  [PDF - 1.4 MB]
• Navigating the challenges in an Era of Opioid Deprescribing: Behavioral Strategies for Patient Engagement and Success Exit Disclaimer: You Are Leaving www.ihs.gov  [PDF - 4 MB]
• CDC Clinical Practice Guideline for Prescribing Opioids for Pain – United States, 2022 Exit Disclaimer: You Are Leaving www.ihs.gov