Appendix

Table 8. Socio-Economic Barriers to Effective Pain Management

Geographic barriers (i.e., access to care)

Unstable housing

Employment

Lack of transportation

Lack of social support

Lack of education

Adapted from
Hooten M, Thorson D, Bianco J, et al. Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management. URL: https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_neurological_guidelines/pain/. Updated: August 2017. Accessed: June 22, 2020.

Table 9. Single Modality Interventions for Patients with Chronic Non-Cancer Pain

Modality	Technique	Comments
Ablation	Chemical denervation, cryoneurolysis or cryoablation, thermal intradiscal procedures, and radiofrequency ablation	Other treatment modalities should be attempted before consideration of these techniques.
Acupuncture	Traditional or electroacupuncture	May be considered as an adjuvant to conventional therapy in the treatment of nonspecific, noninflammatory low back pain.
Blocks	Joint, nerve, or nerve root block	Sympathetic nerve blocks should not be used as long-term treatments of non-complex regional pain syndrome neuropathic pain. Peripheral somatic nerve blocks should not be used for long-term treatment of chronic pain.
Botulism Toxin	Type A	Should not be used in routine care of patients with myofascial pain.
Electrical Nerve Stimulation	Subcutaneous peripheral nerve stimulation, spinal cord stimulation, and transcutaneous electrical nerve stimulation	Usually used in a multimodal treatment approach.
Epidural Steroid Injections	With or without local anesthetics	May be used in select patients with radicular pain or radiculopathy
Intrathecal drug therapies	Neurolytic blocks, intrathecal nonopioid injections, intrathecal opioid injections	Intrathecal neurolytic blocks should not be performed in the routine management of patients with non-cancer pain.
Adapted from: American Society of Anesthesiologists Task Force on Chronic Pain Management. Anesthesiology. 2010;112:810-833.

Table 10 . ICSI Recommendations for Preventing Avoidable Harm from Opioids

Recommendation	Comments
Do not prescribe opioids for the long-term treatment of pain unless risks and benefits have been thoroughly assessed	Pain should be managed with non-pharmacologic treatments and non-opioid medications when possible. If opioids must be prescribed, they should be used at the lowest possible dose in combination with non-drug and non-opiate treatments.
Due to an increased risk of death with higher doses, make every effort to maintain patients on daily doses ≤ 100 morphine mg equivalents	Consider consulting with a pain management specialist for higher doses.
Avoid prescribing opioids in patients who have a substance use disorder or who are receiving concomitant benzodiazepine therapy	If opiates must be prescribed in these circumstances, the dose should be ≤ 50 morphine mg equivalents. Consider referring patients with a substance use disorder to an addiction medicine specialist.
Due to the risk of overdose and death, avoid the use of ER/LA opioids except in patients who have opioid tolerance and will be adherent to the treatment plan	Use tamper-resistant, also called “abuse-deterrent”, formulations when possible to discourage use other than as prescribed (e.g. inhaled or injected). Although clinical evidence to support the true value of tamper-resistant formulations is still evolving, this is a common-sense practice.
Avoid prescribing methadone	Due to its lipophilic nature and unpredictable pharmacokinetics, specific knowledge and experience is required to avoid accidental overdose. Use of methadone should be reserved for experienced clinicians and possibly only for patients suffering from opioid addiction. Buprenorphine can be prescribed more safely (with proper licensing).
Advise patients recently prescribed opioids and those whose dose has been increased to not operate heavy machinery, drive a car, or participate in other activities that may be affected by sedation	Assess the risks and benefits of driving and other high-risk activities in patients on COT with established tolerance.
Repeatedly discuss appropriate storage to prevent unauthorized access	Appropriate disposal methods of excess opioids include pill take-back sites and pharmaceutical disposal bags.
Consider offering a naloxone kit to patients and their close contacts	Community administration of naloxone may save the life of a person who would otherwise die from an opioid overdose. However, training is required to use it properly. Numerous community-based programs offer naloxone kits as well as training.
Screen older patients for risk of harm, including falls, cognitive impairment, respiratory failure, and renal insufficiency before prescribing	Initiate therapy at 50% of the usual dose.
Patient-provider agreements can be initiated as a tool for shared decision-making	Consider an agreement in patients who 1) are high-risk, 2) use opioids daily for > 30 days, 3) use opioids intermittently for up to 90 days at a time, 4) and new patients already on opioids prescribed by another provider. Otherwise, consider an agreement if opioid use exceeds 90 days.
Adapted from: Hooten M, Thorson D, Bianco J, et al. Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management. URL: https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_neurological_guidelines/pain/. Updated: August 2017. Accessed: June 22, 2020.