Chronic Pain Guidleines

Managing chronic non-terminal pain including prescribing controlled substances.

FDA WARNING/REGULATORY ALERT

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

* December 16, 2008 - Antiepileptic drugs: The U.S. Food and Drug Administration (FDA) has completed its analysis of reports of suicidality (suicidal behavior or ideation [thoughts]) from placebo-controlled clinical trials of drugs used to treat epilepsy, psychiatric disorders, and other conditions. Based on the outcome of this review, FDA is requiring that all manufacturers of drugs in this class include a Warning in their labeling and develop a Medication Guide to be provided to patients prescribed these drugs to inform them of the risks of suicidal thoughts or actions. FDA expects that the increased risk of suicidality is shared by all antiepileptic drugs and anticipates that the class labeling change will be applied broadly.

Major Reccomendations

Note from the National Guideline Clearinghouse (NGC): The following key points summarize the content of the guideline. Refer to the full text of the original guideline document for additional information, including detailed information on the evaluation and management of chronic pain and selected medications for chronic pain.

The levels of evidence [A-D] and strength of recommendation [I-III] are defined at the end of the "Major Recommendations" field.

Diagnosis

Chronic pain is different from acute pain. It requires comprehensive physical, functional, behavioral and psychosocial assessment.

• History. Pain history should include a detailed description of symptoms, initiating injury or event, detailed treatment history, pain-related disability, psychiatric comorbidity, social stressors and barriers to care (e.g., insurance, education, pharmacy access, support systems). [ID]
• Exam and laboratory findings. Physical exam findings and radiographic studies may identify opportunities for procedural interventions or surgery, but these findings often do not correlate with symptom severity, degree of disability or appropriate intensity of treatment. [IID]
• Opioids and addiction risk. If opioid analgesics have been used or are being considered, dependence and addiction risk should be assessed through careful personal and family history, review of outside records and assessment of illicit or prescription medication misuse. Check the state prescription monitoring system [in Michigan, Michigan Automated Prescribing Service (MAPS)] and perform a urine screen by combination of enzyme immunolinked assay (EIA) and gas chromatography/mass spectroscopy (GCMS) prior to prescribing and at least yearly for patients given chronic opioid therapy. [ID]

Treatment

Treatment should be multi-dimensional, not merely pharmacological. Effective therapy should control chronic pain in order to improve function at work, home, socially and in pleasurable pursuits. Complete analgesia is not possible for many patients, nor should it be the goal of therapy.

• Expectations. Patient and provider expectations should be articulated clearly at the beginning of treatment and reviewed regularly. A written controlled substance treatment agreement is appropriate for most patients treated with ongoing daily opioid therapy. [ID]
• Non-pharmacologic therapies. Begin with these therapies (e.g., exercise, heat, sleep hygiene).
• Medical treatment. Choose drugs based on presumed pain type and the patient's comorbidities.
  • Non-steroidal anti-inflammatory drugs (NSAIDs) and/or acetaminophen can be effective for chronic musculoskeletal or arthritis pain. In older adults, non-steroidal anti-inflammatory drugs and cyclooxygenase-2 (COX-2) inhibitors should be used rarely and with caution, monitoring for gastrointestinal (GI) and renal toxicity, hypertension, and heart failure. [ID]
  • Adjuvant medications Tricyclic antidepressants (TCAs), serotonin-norepinephrine reuptake inhibitors (SNRIs) (duloxetine) and second generation anticonvulsant medications are effective for specific neuropathic pain states. [IA] For central pain/fibromyalgia, TCAs, SNRIs, gabapentin and pregabalin are effective. [IA]
  • Opioid analgesics can be safe and effective for some patients with chronic non-terminal pain [IIB], but require careful patient selection, titration and monitoring. Scheduled, long-acting opioids, (morphine extended-release [ER], or methadone, buprenorphine) are preferred for continuous treatment [ID]. OxyContin is not truly long-acting and has a higher risk for misuse or diversion. Avoid long-term, daily treatment with short-acting opioids and opioid combinations (e.g., Vicodin, Norco, Percocet). For "as needed" (PRN) dosing, prescribe small amounts expecting monthly (not daily) use.

Follow-up

Reassessment should center on achieving shared treatment goals and improved function.

• Frequency. Patients should be seen frequently (weekly to monthly) during initial evaluation and treatment, and at least quarterly thereafter. [ID]
• Assessment. Reassess physical, psychological and social domains regularly, particularly progress toward improved function. [ID]
• Ineffective treatments. Stop ineffective treatment modalities (e.g., non-steroidal anti-inflammatory drugs, opioids). [ID]
• Opioids and problem use. Monitor patients receiving opioid analgesics for misuse with Michigan Automated Prescribing Service assessments and random urine comprehensive drug screens by enzyme immunolinked assay and gas chromatography/mass spectroscopy (EIA-GCMS). [IID]
• Referral. Referral to pain management specialist should be considered for failure to achieve treatment goals, intolerance of therapies, need for interventional management, need for multidisciplinary treatment, need for excessive opioid doses, suspicion of addiction, or opioid misuse. [IB]

Definitions:

Levels of Evidence

1. Randomized controlled trials
2. Controlled trials, no randomization
3. Observational trials
4. Opinion of expert panel

Strength of Recommendation

1. Generally should be performed
2. May be reasonable to perform
3. Generally should not be performed

CLINICAL ALGORITHM(S)

None provided

Reference:

University of Michigan Health System. Managing chronic non-terminal pain including prescribing controlled substances. Ann Arbor (MI): University of Michigan Health System; 2009 Mar. 34 p. [11 references]