Standard of Care Recommendations

Assessment Recommendations

History and physical examination	A thorough history and physical examination should be performed with the goal of obtaining a confident diagnosis for the source of the pain. Clinicians should also screen for co-morbidities that might complicate the diagnosis (e.g., dementia) and management (e.g. uncontrolled diabetes in the context of painful diabetic neuropathy) of pain.²
Pain assessment	“OPQRST” may be a useful acronym during the patient interview: Onset, Provocation/Palliation, Quality, Region, Severity (pain score), and Time. Functional status and quality of life should be assessed using validated tools. While the assessment of chronic pain historically focused on the characteristics of the pain, the assessment of the level of functioning is now considered equally important.²
Classification	Based on the history and physical, the patient’s pain should be classified as neuropathic, musculoskeletal, inflammatory, visceral, or opioid-induced (Table 1 ).²
Behavioral health assessment	Patients with chronic pain are four times more likely to have clinical depression compared to patients without pain and severe pain predicts a failure to respond to depression treatment. Similarly, anxiety, panic, personality disorders, and post-traumatic stress also have associations with chronic pain. Given the overlap between behavioral health conditions and chronic pain, it is recommended to identify and treat both for optimal outcomes.^2,9
Substance abuse assessment	The presence of a substance use disorder complicates the diagnosis of chronic pain and affects aspects of management, including drug selection, monitoring, and the risk of opioid misuse and abuse. Clinicians should screen for substance use disorder and chronic opioid use in all patients with an unclear etiology of pain.² Electronic medical records and prescription drug monitoring programs, where available, can be tools to assess possible substance abuse.
Determine barriers to treatment success	Treatment failure can result from a single or combination of socioeconomic factors, including: lack of resources, lack of support, unemployment, or disability. Clinicians should attempt to identify and address socioeconomic barriers that would impair the patient’s ability to adhere to the treatment plan (Table 7 ).²

Treatment Recommendations

Shared decision-making	Set realistic goals and expectations only after eliciting the patient’s needs, goals, beliefs, values, and preferences. Since complete resolution of pain is often unrealistic, specific and measurable goals related to quality of life, function, and comfort should be emphasized. Motivational interviewing techniques may be useful for establishing and strengthening patient motivation for change.²
Multidisciplinary approach	Given the complex nature of pain and the diverse treatment options, guidelines from the Institute for Clinical Systems Improvement (ICSI) recommend a multidisciplinary approach to its management, including access to psychologists, addiction treatment specialists, physical therapists, interventionists, and pain management specialists.² Some of these specialists may be able to provide services through telemedicine
Comprehensive treatment plan	A mutually agreed upon care plan should be created and documented. Treatments should be chosen based on 1) the source/mechanism of pain, 2) pain severity and functional consequences, 3) co-morbidities, 4) goals of treatment, 5) available treatment options, and 6) patient barriers, burdens, and their capacity to adhere to the plan.²
Non-pharmacological therapy	Non-drug treatments should be emphasized over pharmacologic therapy. Psychotherapy (e.g., cognitive behavioral therapy) and physical activity should be part of the routine management of chronic pain.^2,10 Other non-drug approaches include complementary and integrative medicine (e.g., acupuncture, mind-body practices), physical rehabilitation (e.g., physical therapy, spinal manipulation), and interventional medicine.²
Pharmacotherapy	Pharmacotherapy should be used as an adjunct to non-pharmacological treatments for chronic pain.2 Non- opioid medications should be considered before opioid therapy.^2,11
Opioid use for acute or acute-on-chronic pain	Prescribe low-dose, short-acting, immediate-release opioids for initial treatment of acute or acute-on-chronic pain. Initial treatment should be for the lowest effective dose (total dose ≤ 100 morphine mg equivalents) for ≤ 3 days. No opioid has been conclusively proven to be superior to another. Opioid selection, initial dose, and titration schedule should be individualized according to patient-specific (e.g., age, comorbidities, concomitant medications, previous exposure to opioids, therapeutic goals, and predicted or observed harms) and drug-specific (e.g., pharmacokinetics, delivery mechanisms, cost, drug interactions, and potential adverse events) factors.2²
Opioid use for chronic pain	The ICSI explicitly recommends against using opioids to treat chronic pain. Chronic pain is a complex, whole-person problem that requires a multidisciplinary approach. If opioid therapy is unavoidable, ICSI recommends against using doses > 100 morphine mg equivalents without consultation with a pain management specialist.²
Long-acting opioid formulations	Evidence fails to support that extended-release (ER) and long-acting (LA) opioids improve pain control or function, but suggests that they can increase the risk of overdose death. However, some patients with both documented opioid tolerance and medication adherence can benefit from long-acting opioids.² The FDA has warned that ER/LA opioids are not appropriate for moderate pain and should only be used for pain severe enough to require long-term, around-the-clock opioid treatment and for which alternatives would provide inadequate analgesia. ER/LA opioids are not indicated for use on an as-needed basis. ¹¹
Potential harms of chronic opioid therapy	The effectiveness of long-term opioids has not been firmly established, but is associated with an increased risk of harm, including misuse, abuse, dependence, fatal and non-fatal overdose, CV events, endocrine abnormalities, and road trauma. Opioids should only be considered when an individualized assessment suggests that the anticipated benefits outweigh the risks. When used, opioids should be combined with non-opioid therapies when appropriate.⁶
Preventing avoidable harm from opioids	Evidence suggests that the risks of COT exceed the demonstrable benefits for most patients.⁶ Providers can prevent avoidable harm from opioids by carefully selecting the drug and formulation, limiting doses, and considering the risk of harm before prescribing (Table 3).²
Follow-up assessments	Evaluate the benefits and harms of opioid therapy within 1 month of initiation and at least every 3 months thereafter to proactively prevent opiate-related harms.²
Multiple prescribers and risk of harm	Elderly patients who receive opioid prescriptions from multiple prescribers may be at higher risk of opioid-related hospitalization.¹²
Preventing avoidable harm from opioids	Providers can prevent avoidable harm from opioids by carefully selecting the drug and formulation, limiting doses, and using caution in high-risk patients.¹
Muscle relaxants	Muscle relaxants (e.g., carisoprodol, benzodiazepines) should generally be avoided in the treatment of chronic pain. They are generally only marginally effective, yet have significant CNS depressant effects that are additive to other depressants, such as opioids.²
Opioid tapering and discontinuation	Consider discontinuing opioids + taper every 6 months, particularly in patients with evidence of opioid-related harm, patients at high risk for harm, and those displaying inappropriate behavior (e.g., violations of patient expectations, diversion, abuse). Patients on low doses for short durations (e.g., < 90 days) may not need a taper; however, every situation should be individualized.²