You are here: Home > Physician Resource Page > Narcotics in the Management of Chronic Non-Malignant Pain

Whats New...

General Principles of Appropriate Pain Management with Opioids

Evaluation of the patient

  1. Each patient with CNCP should be thoroughly evaluated before the institution of long term opioid therapy. If possible, the specific cause of the pain should be determined, and specific therapy, if available, should be offered. Evaluation of the patient should include at least the following information:

    1. a detailed pain history and the results of previous treatments;

    2. assessment of the impact of pain on the patient's family or significant others;

    3. a directed physical examination, including musculoskeletal examination, to look for clues to specific pain syndromes;

    4. a review of previous diagnostic studies and assessments. Additional investigation or consultation, if required, to fill in gaps in the previous diagnostic work-up;

    5. an assessment of coexisting illnesses and treatments, and their effect on the patient and on the pain; and

    6. an assessment of significant psychological, social or behavioural factors that may affect the current pain problem or future treatment plans. This includes an assessment of risk factors for addiction.

  2. A complete assessment of the pain problem must precede the initiation of a trial of opioid therapy, but this does not require the duplication of previous investigations or consultations.

  3. When a specific curable pain syndrome cannot be diagnosed, it may be useful, both for research purposes and clinically, to classify the type of pain into three main categories based on the inferred pathophysiology.

    Troublesome nociceptive pain is usually due to continuous stimulation of specialized pain receptors in such tissues as the skin, bones, joints and viscera. It is often indicative of ongoing tissue damage. Typical examples include osteoarthritis and chronic pancreatitis.

    Neuropathic pain is due to nerve damage or abnormal processing of signals along the pain systems of the peripheral and central nervous system. Examples include postherpetic neuralgia, phantom limb pain, pain resulting from spinal cord injuries and sympathetically mediated pain. Most chronic pain syndromes involve one or both of the above mechanisms. Occasionally, a patient's pain pattern may not precisely fit into either of the above categories. Previous guidelines have labelled this type of pain as idiopathic. As knowledge evolves regarding central and peripheral sensitization of the central nervous system pain systems it is likely that many types of idiopathic pain will turn out to have a nociceptlve or neuropathic origin or a mixture of the two.

  4. Nociceptive and neuropathic pain syndromes can both be considered for a trial of opioid therapy. Patients with neuropathic pain may require higher doses of opioid therapy to achieve significant analgesia and may benefit from the concurrent use of adjuvant analgesics from the tricyclic antidepressant, anticonvulsant or antiarrhythmic classes. Idiopathic pain may also be an indication for opioid therapy, but previous guidelines have suggested that a trial of opioids be prescribed cautiously with specific goals and careful monitoring to document an ongoing benefit.

  5. All types of pain may have a significant affective or psychological component. Depressive symptoms frequently accompany CNCP and contribute to patient suffering. It is generally accepted by pain specialists that depression is more likely to be a secondary effect of the pain itself, rather than the reverse. Some patients with chronic pain and symptoms of major depression may demonstrate decreased suffering when depression is treated. For others, depressive symptoms diminish when pain is adequately treated. The term 'psychogenic pain' has been used to define pain that is believed to be caused by or primarily influenced by a psychopathological process. The use of this term is discouraged because it lacks precision and has the potential to stigmatize patients when applied inappropriately. True primary psychological pain disorders are rare (26) and should be classified using criteria of the International Association for the Study of Pain or the DSM-IV (27,21).

  6. An important component of the psychosocial evaluation for opioid therapy is the assessment of the risk of addiction. Because an unrecognized addictive disorder can complicate the treatment of chronic pain. it is worthwhile to screen patients to identify those who may need more detailed assessment. A basic, suggested set of screening questions is included as Appendix 1 to this document. Patients with a past history of addiction should not necessarily be denied a trial of opioid therapy, but will require more careful prescribing and follow-up.

  7. Treatment plan: The treatment plan should be individualized to the patient and to the pain problem. The physician should consider the gamut of appropriate treatment approaches, including physical methods, multidisciplinary pain management programs, cognitive and behavioural strategies, pharmacotherapy, and various other invasive and noninvasive techniques. The choice may depend on many factors such as cost, availability of timely services and comorbidity, as well as physical and psychosocial impairments related to the pain. For some patients, simply decreasing the severity of their pain is all that is required to improve their quality of life. For others, a more intensive comprehensive treatment plan that addresses the psychological, social and behavioural contributors to their suffering is required.

  8. In most circumstances, a trial of scheduled long term opioid therapy may be indicated for patients who have failed to respond to a reasonable documented trial of nonpharmacological and nonopioid pharmacological modalities.

  9. The primary purpose of long term opioid therapy should be improved quality of life for the patient. Therefore, improved pain control is a reasonable and appropriate goal of treatment. In CNCP it is usually not realistic to set a goal of total elimination of the pain. Instead, the patient and physician need to negotiate a treatment plan to find the optimum balance of pain relief, functional improvement and medication side effects. To help patients improve their level of physical and psychological function, it is often useful to develop with the patient a list of functional goals. These goals might include specific targets for physical activity, performance of activities of daily living, hobbies or return to work. The attainment of these goals can be used as evidence of the efficacy of long term opioid therapy. However, failure to achieve fully all functional goals should not necessarily be construed as a therapeutic failure. On the other hand, a persistent decline in physical or psychological function in association with institution of opioid therapy should cause the physician to reassess carefully the benefits of ongoing treatment with opioids. In some cases, a gradual dose reduction possibly leading to discontinuation of opioid therapy may be required.

  10. If a trial of opioid analgesics is selected, the physician should obtain informed consent from the patient or the patient's guardian. Informed consent should include discussion of the risks and benefits of opioid therapy, as well as the conditions under which opioids will be prescribed. A suggested list of discussion points is included in Appendix 2. In most practice settings in Canada a documented verbal consent will usually suffice. For patients assessed to be at higher risk of noncompliance with the agreed upon treatment plan, physicians may find it helpful to use a written therapeutic agreement, setting out the terms and conditions for prescribing opioid therapy. A sample blank agreement has been included in Appendix 3.

  11. When prescribing an opioid analgesic for around-the-clock pain, it should also be dosed around-the-clock in a pharmacologically appropriate, time-contingent, dosing schedule. There is no pharmacological rationale for a dose ceiling for opioids. Long term opioid therapy should be started at a low dose and carefully titrated until an adequate level of analgesia is obtained, or until unmanageable and persistent side effects warrant a decreased dose or a change in therapy. For opioid-naive patients, failure to realize at least partial analgesia with incremental dosing may indicate a pain syndrome that is less responsive to opioids. For some patients, however, opioids do not exert an appreciable analgesic effect until a threshold dose has been achieved. Use of an opioid with a long duration of action has many advantages for treating chronic pain. It can facilitate patient compliance with around-the-clock dosing; can provide a more consistent blood level, thereby allowing better tolerance to side effects, such as cognitive impairment and may reduce the reinforcement of pain behaviour based on as required dosing regimens. During the titration phase, reasonable doses of breakthrough opioid may be provided and can be used to assess the adequacy of the overall opioid dose. A goal of optimal opioid titration for a stable chronic pain condition is to decrease the frequency of breakthrough doses to a minimum.

  12. Consultation as needed: Consultation with a specialist in pain medicine or with a pain psychiatrist or psychologist may be warranted, depending on the expertise of the practitioner and the complexity of the presenting problem. Consultants in pain medicine are not always available on a timely basis to primary care physicians. Therefore, a consultation with a specialist in pain management should not be a prerequisite to the use of opioid therapy. The presence of addiction or a comorbid psychiatric disorder may require co-management with a specialist in addiction medicine or a psychiatrist, respectively.

  13. Periodic review of the patient: Periodic review of the patient is an essential part of ongoing management with opioid therapy. As with the initial evaluation of the patient, reassessment of the patient's pain is based mainly on the patient's self-report. In assessing the efficacy of opioid therapy, it may be helpful to use collateral sources of information, such as family members, employers, etc. Periodic reexamination is warranted to assess the nature and evolution of the pain complaint and to ensure the ongoing benefit of opioid therapy. It is recommended that the following points be specifically covered at follow-up visits.

    1. Record the patient's self-reported level of pain using some type of quantitative scale such as a Visual Analogue Scale or a verbal rating scale from O to 5 or from O to 10.

    2. Record the level of physical and psychological function, listing specific activities where appropriate.

    3. Record any side effects of opioid therapy (such as drowsiness, nausea and vomiting, constipation and sweating) and their management.

    4. Record any suspicious drug-seeking or other aberrant behaviours observed by the physician or reported by others, along with the action taken by the physician.

    5. If writing a prescription for opioid therapy, be certain to record the name of the drug, the strength, the number of dosage units and how the drug is to be taken. Record any changes to opioid therapy and the reasons for them.

  14. The adverse effects of opioid therapy may sometimes contribute to a persistent decrease in function. In some cases, a gradual reduction in the dosage of opioid therapy - possibly leading to discontinuation of therapy - may be the appropriate course of action.

  15. Documentation: Documentation is essential to demonstrate the evaluation process, including consultations and relevant investigations, the rationale for long term opioid therapy in the context of the overall management plan and the periodic review of patient status. In addition, documentation is required to demonstrate compliance with federal controlled substance legislation.

REFERENCES

  1. Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well-being. A World Health Organization study in primary care. JAMA 1998;280:147-51.
  2. Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. JAMA 1998;279:1877-82.
  3. Somerville MA. Opioids for chronic pain of non-malignant origin Coercion or consent? Health Care Analysis 1995;3:12-4.
  4. The Canadian Pain Society. Position Statement on Pain Relief. Ottawa: Canadian Pain Society, 1997.
  5. Hagen NA, Flynne P, Hays H, MacDonald N. Guidelines for the management of chronic non-malignant pain. Opioids and other agents. Can Fam Physician 1995;41:49-53.
  6. The College of Physicians and Surgeons of Alberta. Guidelines for management of chronic non-malignant pain. Edmonton: College of Physicians and Surgeons of Alberta, 1993.
  7. Goldman B, Gale G, Gilchrist G, Jacobs H, Kerr I, Rothbart P. Use of opioid analgesics for the treatment of chronic pain of nonmalignant origin. A discussion paper from the Probationary Section on Chronic Pain of the Ontario Medical Association. Pain Res Manage 1997;2:231-7.
  8. The use of opioids for the treatment of chronic pain. A consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clin J Pain 1997;13:6-8.
  9. McNairy SL, Maruta T, Ivnik RJ, Swanson DW, Ilstrup DM. Prescription medication dependence and neuropsychologic function. Pain 1984;18:169-77.
  10. Portenoy RK. Opioid therapy for chronic nonmalignant pain. Pain Res Manage 1996;1:17-28.
  11. Arkinstall W, Sandler A, Goughnour B, Babul N, Harsanyi Z, Darke AC. Efficacy of controlled-release codeine in chronic non-malignant pain: a randomized, placebo-controlled trial. Pain 1995;62:169-78.
  12. Moulin DE, lezzi A, Amireh R, Sharpe WK, Boyd D, Merskey H. Randomised trial of oral morphine for chronic non-cancer pain. Lancer 1996;347:143-7.
  13. Crook J, Tunks E. Epidemiologic comparison of persistent pain sufferers in a specialty pain clinic and in the community. Arch Phys Med Rehabil 1986;67:451-5.
  14. Watson CP, Babul N. Efficacy of oxycodone in neuropathic pain: a randomized trial in postherpetic neuralgia. Neurology 1998;50:1837-41.
  15. American Society of Addiction Medicine. Public policy statement on the rights and responsibilities of physicians in the use of opioids for the treatment of pain. Chevy Chase: American Society of Addiction Medicine, 1997.
  16. American Society of Addiction Medicine. Public policy statement on definitions related to the use of opioids in pain treatment. Chevy Chase: American Society of Addiction Medicine, 1997.
  17. Fishbain DA, Rosomoff L, Rosomoff DS. Drug abuse, dependence, and addiction in chronic pain patients. Clin J Pain 1992;8:77-85.
  18. Brown RL. Patterson JJ, Rounds LA, Papasouliotis O. Substance abuse among patients with chronic back pain. J Fam Pract 1996;43:152-60.
  19. Dunbar SA, Katz NP. Chronic opioid therapy for non-malignant pain in patients with a history of substance abuse: Report of 20 cases. J Pain Symptom Manage 1996;11:163-71.
  20. Kennedy JA, Crowley TJ. Chronic pain and substance abuse: a pilot study of opioid maintenance. J Subst Abuse Treat 1990;7:233-8.
  21. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4rd edn, revised. Washington: American Psychiatric Association, 1994.
  22. Lorenz J, Beck H, Bromm B. Cognitive performance, mood and experimental pain before and during morphine-induced analgesia in patients with chronic non-malignant pain. Pain 1997;73:369-75.
  23. Haythornthwaite JA, Menefee LA. Outcome of chronic opioid therapy for non-cancer pain. J Pain Symptom Manage 1998;15:185-94.
  24. Vainio A, Ollila J, Matikainen E, Rosenberg P, Kalso E. Driving ability in cancer patients receiving long-term morphine analgesia. Lancer 1995;346:667-70.
  25. Zacny JP. Should people taking opioids for medical reasons be allowed to work and drive? Addiction 1996;91:1581-4.
  26. Merskey H. Psychiatry and chronic pain. Can J Psychiatry 1989;34:329-36.
  27. Merskey H, Bogduk N, eds. Classification of Chronic Pain. Descriptions of Chronic Pain Syndromes and Definitions of Terms. International Association for the study of Pain (IASP). Seattle: IASP Press, 1994.

APPENDIX 1

Suggested addiction screening questions

In screening patients with chronic noncancer pain for addiction risk, the clinician is primarily interested in assessing for patients with a history of alcohol abuse/dependence or with a history of polydrug abuse. A patient who has a past history of abusing one substance is at higher risk for abusing other psychoactive substances. The purpose of screening is not to deny patients opioids for pain, but to identify the small subgroup at higher risk for more detailed assessment and more careful monitoring.

The Screening Instrument For Substance Abuse Potential (SISAP) is a five-item screening tool created by Coambs et al in 1996 (1) that helps the clinician to categorize patients into lower or higher risk of abusing prescribed opioids. It requires that the physician already know the patient or have collateral information to confirm the accuracy of the answers. It has a high false positive rate but a low false negative rate when tested against the database of a large (n=11,634) Canadian epidemiological survey of alcohol and drug use. It has not yet been prospectively tested in the chronic pain population.

The five SISAP questions are:

  1. If you drink alcohol, how many drinks do you have on a typical day?

  2. How many drinks do you have in a typical week?

  3. Have you used marijuana or hashish in the past year?

  4. Have you ever smoked cigarettes?

  5. What is your age?

Use caution when prescribing opioids for the following patients:

  1. Men who exceed four drinks per day or 16 drinks per week

  2. Women who exceed three drinks per day or 12 drinks per week

  3. A patient who admits to marijuana or hashish use in the past year. (It is recreational use of cannabis for euphoric effect that is of concern. The use of tetrahydrocannabinol (THC) derivatives to treat pain is still very controversial. Clinicians should exercise caution in recommending opioid therapy to a patient who is using cannabis regularly.)

  4. A patient under 40 years who smokes.

The majority of patients will pass the screen and are probably at low risk of abusing opioids, but clinical judgement is still required. The SISAP questions ask about recent drug or alcohol use and may, therefore, miss a patient who is at risk because of a previous history of chemical abuse or dependency. A simple but effective question to ask is:

Has your use of alcohol or other drugs ever caused a problem for you or those close to you?

A positive answer to the above or to any of the SISAP questions suggests further assessment.

The CAGE-AID questions comprise a quick screening tool to assess for the risk of serious alcohol or drug problems.

In the past have you ever:

  1. felt that you wanted or needed to Cut down on your drinking or drug use?

  2. been Annoyed by others' complaining about your drinking or drug use?

  3. felt Guilty about the consequences of your drinking or drug use?

  4. had a drink or taken a drug in the morning (Eye-opener) to decrease hangover or withdrawal symptoms?

One positive response to any one of the CAGE-AID questions should raise concerns. Two or more positive responses means a high likelihood of a serious alcohol or drug problem and may require a formal addiction assessment by a specialist.

A family history of alcohol, drug abuse or significant psychiatric illness, or a personal history of previous physical, sexual or emotional abuse may also be risk factors for substance abuse and require assessment.

REFERENCE

  1. Coambs RE, Jarry JL, Santhiapillai AC, Abrahamsohn RV, Atance CM. The SISAP: A new screening instrument for identifying potential opioid abusers in the management of chronic nonmalignant pain in general medical practice. Pain Res Manage 1996;1:155-62.

APPENDIX 2

Discussing opioid therapy with the patient - suggested points of discussion

  1. Describe and explain the purpose of opioid therapy (less pain rather than no pain) with the patient and/or guardian, along with explaining the common side effects and their management. Preventative management of constipation should specifically be discussed. The small risk of addiction in low risk patients should be addressed and differentiated from tolerance and physical dependence. Warn the patient regarding withdrawal symptoms due to abrupt discontinuation of opioids. Discuss the concept of dose titration and the importance of time-contingent dosing versus as required dosing for around-the-clock pain. Discuss the appropriate use of breakthrough medication.

  2. Advise the patient and/or guardian that drowsiness is a common side effect during titration of opioid therapy. The patient should not drive a car or operate dangerous machinery until this phase of drowsiness has passed. Failure to comply with this advice may result in a duty to report to the provincial Ministry of Transportation.

  3. The patient and/or guardian should be warned not to change the dosage of opioid analgesic nor the dosing interval without specific instructions from the doctor. The patient should be made aware that such unsanctioned dosage changes may compromise the physician-patient relationship.

  4. Inform the patient and/or guardian that regular follow-up appointments are required to monitor the effectiveness of opioid treatment and to manage side effects. The frequency of follow-up appointments will vary depending on the phase of treatment - titration versus stable dosing.

  5. Inform the patient and/or guardian that prescriptions for opioid analgesics should be obtained only from one physician or, in the absence of that physician, his or her designate. The patient should have all prescriptions for psychoactive medication dispensed at one pharmacy, except in emergencies. Inform the patient and/or guardian that seeking opioid treatment from other physicians and pharmacies without informing the prescribing physician undermines the trust essential to prescribing long term opioid therapy.

  6. Advise the patient and/or guardian to keep the opioid analgesics in a safe and secure place, and to not give, lend or sell the medication to anyone.

  7. Warn the patient and/or guardian that there is a potential for significant cognitive dysfunction if opioids are combined with sedatives such as benzodiazepines, barbiturates, muscle relaxants, or alcohol. The patient and/or guardian should be warned not to consume any of the above substances without first discussing this with the physician.

  8. Although the potential for abuse or addiction to prescribed opioid analgesics is small in low risk patients, the concurrent abuse of illicit substances such as marijuana, cocaine, stimulants, hallucinogens, heroin or the consumption of alcohol in a high risk pattern identifies an individual at increased risk of also abusing opioids. The use of these substances may also interfere with the therapeutic effect of opioids or cause increased side effects such as cognitive dysfunction. It is therefore advisable that the patient abstain from taking any psychoactive substances without first discussing this with the physician. Advise the patient and/or guardian that the physician may, from time to time, take specific actions to monitor for this possibility such as periodic blood and/or urine drug screening. This may also include an assessment with a specialist in addiction medicine.

  9. Inform the patient and/or guardian that, as part of ongoing treatment, the physician may request additional consultations and assessments, or recommend other concurrent treatment modalities. The clinician should carefully re-evaluate a patient who consistently refuses to cooperate with recommendations for treatments other than opioid therapy.

  10. Inform the patient and/or guardian that, aside from better pain control, a key measure of the efficacy of long term opioid therapy is improved physical and psychological function at home and/or work. The patient and the physician may, therefore, discuss a set of reasonable specific functional goals. The physician will assess progress towards these goals at each visit and will use this information in evaluating the overall success of long term opioid therapy. Persistent functional decline on opioids may result in re-evaluation of the patient and a reassessment of the treatment plan.

APPENDIX 3

Sample basic patient agreement (for patients at higher risk of noncompliance with opioid therapy)

  1. I, agree that Dr will be the only physician prescribing OPIp;OID (also known as NARCOTIC) pain medication.

  2. I will take the medication at the dose and frequency prescribed by my physician. I agree not to increase the dose of opioid on my own and understand that doing so may lead to the treatment with opioids being stopped.

  3. I will attend all appointments, treatments and consultations as requested by my physician.

  4. I will not receive opioid pain medications from any other physician except in an emergency or in the unlikely event that I run out of medication. Should such occasions occur, I will inform my prescribing physician as soon as possible.

  5. I understand that the common side effects of opioid therapy include nausea, constipation, sweating and itchiness of the skin. Drowsiness may occur when starting opioid therapy or when increasing the dosage. I agree to refrain from driving a motor vehicle or operating dangerous machinery until such drowsiness disappears.

  6. I understand that there is small risk that I may become addicted to the opioids I am being prescribed. As such, my physician may require that I have additional tests and/or see a specialist in addiction should a concern about addiction arise during my treatment.

  7. I understand that the use of any mood-modifying substance, such as tranquilizers, sleeping pills, alcohol or illicit drugs (such as cannabis, cocaine, heroin or hallucinogens), can cause adverse effects or interfere with opioid therapy. Therefore, I agree to refrain from the use of all of these substances without first discussing it with my physician.

  8. I agree to be responsible for the secure storage of my medication at all times. I agree not to provide my prescribed pain medication to any other person.

  9. If I break this agreement, my physician reserves the right to stop prescribing opioid medications for me.

  10. I hereby agree that my physician has the authority to disclose the prescribing information in my patient file to other health care professionals when it is deemed medically necessary in the physician's judgement.