Lumeris' Most Important Considerations

Psychotherapy and regular exercise should be considered in all patients with chronic pain.

Pain is a subjective, personal experience. While it is generally not realistic to expect or achieve complete pain resolution, it is possible for patients to alleviate suffering by constructively altering their relationship with pain. Evidence suggests that psychotherapeutic interventions result in reduced perception of pain, increased activity levels, and improved general health and quality of life.²

There are several categories of psychotherapy that may be helpful in the care of patients with chronic pain:²

• Cognitive behavioral therapy (CBT)
• Relaxation and biofeedback
• Mindfulness-based stress reduction
• Hypnosis

Exercise, which improves pain, functional outcomes, and overall health, should be a component of the comprehensive treatment plan in all patients with chronic pain, either in the form of physical therapy, structured exercise programs, or self-directed exercise. While neither the optimal type nor dose of exercise has been elucidated, at least 2-3 sessions per week are recommended. Patients with chronic pain are often deconditioned; therefore, a conservative initial program with progressively increasing intensity is recommended. No single type of exercise has been shown definitively superior to any other.²

Pharmacotherapy should be used as an adjunct to non-pharmacological treatments for chronic pain.

The first step in developing a plan for pharmacotherapy is documentation of a complete medication history, including prescription and non-prescription medications. Ask specifically about herbal medications, dietary supplements, and cannabis or cannabinoids, as some people do not consider them part of their drug regimen. Drug selection should consider potential interactions with other medications as well as patient-specific factors (e.g., age, co-morbidities, end-organ function, allergies).²

Non-opioid analgesics should be considered first-line pharmacotherapy for pain. Different etiologies of pain respond to different non-opioid pharmacologic agents (e.g., topical and oral analgesics, antidepressants, anticonvulsants drugs) alone or in combination.²

Table 1. Classification and Treatment of Chronic Pain

Medication therapy should be undertaken after engaging the patient in discussion and shared decision-making. Misconceptions, questions, and concerns about drug therapy should be identified and addressed so that they do not become barriers to adherence. Prescribe each new medication on a trial basis with one or more clearly defined goals (e.g., “I want medications to so that I can continue to work”). Goals may vary based on mechanism of action and therapeutic desires. If the goal(s) are not met after a trial of adequate duration, the agent in question should be discontinued or supplemented with another agent if safe and appropriate.²

Occasionally, multi-drug therapy using medications with different mechanisms may provide greater analgesia with fewer side effects. However, prescribing multiple medications in the same class concomitantly should generally be avoided.² Each medication has specific considerations related to initiation, dose titration, adverse events, drug interactions, and tapering and discontinuation. Be vigilant for side effects, especially those compounded by other medications.

Due to an excessive risk of addiction and death compared to modest benefits, opioid therapy should generally be avoided for the treatment of chronic non-cancer pain.

The ICSI guidelines recommend against routine use of opioids to treat chronic pain because the risk of addiction and death outweigh the benefits for most patients. Reliable evidence on methods to accurately assess the potential benefits of COT is limited, although randomized trials that demonstrate the benefits of COT are most applicable to patients with moderate-to-severe pain who have not responded to non-opioid therapies.² Before starting, and periodically during, COT, clinicians should 1) discuss the benefits and harms of opioid therapy and the clinician’s responsibilities, 2) set realistic goals for pain relief and function, 3) decide how effectiveness will be evaluated, and 4) establish thresholds for discontinuation if the benefits no longer exceed the risks.¹¹

Although their sensitivity and specificity do not allow them to accurately predict or rule-out opioid-related harm, risk assessment tools such as the Diagnosis, Intractability, Risk, and Efficacy (DIRE) score can provide valuable information to clinicians and patients. Risk assessment alone should not be used to qualify or disqualify patients from opioid therapy. Rather, the information gleaned should be carefully considered while making treatment decisions.¹

Table 2. Potential Risk Factors for Opioid-Related Harm—ABCDPQRS

Elderly patients who receive opioid prescriptions from multiple prescribers may be at higher risk of opioid-related hospitalization.

A retrospective cohort study evaluated more than 1.8 million continuously enrolled Medicare beneficiaries (mean age 69 years) who received at least one prescription for opioids in 2010 (mean 6 prescriptions). Of the 1.2 million patients who filled multiple opiate prescriptions:¹⁷

• 35% received an opioid prescription from two prescribers
• 14% received an opioid prescription from three prescribers
• 12% received an opioid prescription from four or more prescribers

The risk of hospitalization for opioid-related harm was significantly greater in patients who received opioids from multiple prescribers; hospitalization rates were:

• 1.6% for patients with one prescriber
• 2% for those with two prescribers
• 2.9% for those with three prescribers
• 4.8% for those with four or more prescribers

Nearly half of patients with multiple prescribers received opioids from two or more of them at the same time. The most commonly prescribed opioids were hydrocodone/acetaminophen (43%), oxycodone/acetaminophen (12%), and tramadol (12%).

Mis understanding and misapplication of opioid restrictions intended for opioid-naïve patients can lead to harm in opioid-dependent patients.

In January 2019, the Centers for Medicare & Medicaid Services (CMS) began enforcing stringent opioid prescribing limits for opioid-naïve patients including a maximum of 1) 90 mg morphine equivalents (MME) daily, both for individual and cumulative daily opioid amounts, and 2) 7 days of therapy.¹² This correlates with CDC guideline and goes a step further to limit opioid use to the lowest therapeutic dose for the shortest duration. These requirements, which have been adopted by states and insurance clearinghouses alike, has been met with recent criticism from clinical experts.

The American Academy of Pain Medicine Foundation recently organized a multidisciplinary panel of pain management specialists to discuss the limitations of the CDC guideline. They expressed significant concerns about the CDC recommendations for tapering/cessation, dosage limits, comprehensive care, and the diagnosis and treatment of opioid use disorder.¹³

The CDC organized a formal response in April 2019, highlighting areas where misapplication of the guideline recommendations may have put chronic pain patients’ health at risk. They caution primary care practitioners to utilize the guidelines only in the treatment of adults with chronic pain that excludes oncology-related, post-surgical, and acute sickle cell crisis-related pain.¹⁴

The ICSI recommends specific practices to reduce the risk of harm when prescribing opioids (Table 10).¹

Consider referring patients with signs of inappropriate opioid use to an addiction specialist.

The American Psychiatric Society defines an opioid use disorder as, “A problematic pattern of opioid use leading to clinically significant impairment or distress”. Patients with signs of opioid misuse should not be stigmatized; rather, it should be viewed as an adverse event of COT. Clinicians who prescribe opioids should maintain relationships with specialists that can help implement whole-person care, including psychiatrists, physical therapists, pain management specialists, and, critically, addiction medicine specialists. Patients suspected of misusing opioids or having an opioid use disorder should be assessed using a validated tool such as the ASSIST-2 score and referred for treatment.

If unable to refer, address patient’s fears head-on. For instance, fear of opioid withdrawal symptoms may make patients unwilling to address their addictions. Provide facts and counseling targeted to address this fear. In addition, consider pharmacological interventions to address fears, where appropriate.

Table 3. DSM-5 Opioid Use Disorder Definition

Department of Health and Human Services recommends tapering and discontinuation of long-term opioids in select patients who may benefit.

In their clinician’s guide for tapering long-term opioid therapy, the US Department of Health and Human Services (HHS) suggests that optimizing the use of opioids benefits both individual patients and the public at large. Tapering carefully selected patients on long-term therapy may help curtail the unnecessary and unsafe use of opioids.

Table 4. Characteristics of Patients Who May Benefit from Opioid Tapering

Tapering and discontinuation often comes with anxiety over the risk of withdrawal and other harms. Patients who are physically dependent may experience acute withdrawal, hyperalgesia, worsening sleep, or emotional or psychological distress. Some may seek to obtain opioids illegally or turn to illicit drugs for relief. HHS recommends using a collaborative approach, first discussing perceptions of the benefits and risks of opioid therapy with the patient. Emphasize the benefits of dose reduction, which may include improved function, quality of life, and even pain control with fewer adverse effects. In the absence of immediate risk, clinicians have the luxury of time to have additional discussions and obtain patient buy-in, which increases the odds of success. To further minimize the risk of adverse events, avoid 1) tapering or discontinuation when long-term opioid therapy is warranted, 2) rapid tapering or abrupt discontinuation in the absence of life-threatening adverse events, 3) interpreting dosage thresholds as mandates that supersede clinical judgment, 4) dismissing patients from care, and 5) tapering without collaborating with other providers.¹⁶

Emphasize to patients that minimizing the role of opioids does not mean that they are being abandoned or that their pain will not be actively managed. Optimize the use of non-opioid medications and non-pharmacological treatments for pain, including behavioral treatment. Comorbid mental health conditions are common in people with chronic pain and should be managed aggressively prior to attempting a taper; refer patients with severe disorders to a behavior health provider.¹⁶

Opioid tapering regimens should be individualized. Generally, slower tapers (e.g., ≤ 10% per month) are often better tolerated, particularly in patients on longer-term opioid therapy. Faster tapers (e.g., ≤ 10% per week) may be suitable for patients who have been on shorter-term therapy. It may be necessary to pause the taper reduce the taper rate to avoid significant withdrawal symptoms. While short-term withdrawal symptoms (e.g., anxiety, sweating, muscle aches, diarrhea) often resolve within 10 days, significant neuropsychological symptoms (e.g., dysphoria, insomnia), may be present for weeks to months. Adjunctive therapy such as antidiarrheals or alpha2 agonists can reduce discomfort, and may be especially useful with faster tapering schedules. Once the smallest dose is reached, the dosing interval can be extended. Discontinuation can be attempted once patients are no longer taking doses every day.¹⁶

Table 5. Selected Medications

Table 6. Equi-Analgesic Dosing