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Individualizing Pain Plans

Classifying Pain

Identifying pain types is crucial to guide individual pain plans. As mentioned previously, pain can be classified by its duration (acute or chronic), or by its pathways and damage from tissues or nerves (eg, nociceptive, neuropathic, and nociplastic). There are many other sub-categories that these types can fall under and may be reflected in diagnosis codes and help guide treatment decisions. For example, chronic noncancer pain (CNCP) is a type many researchers refer to when discussing opioid treatment.1

There are also common pain types based on the body part affected, which may have an underlying disease (eg, headache, pelvic pain).3 Furthermore, treatment may be directed based on pain from different procedures (eg, post-surgical, post-cancer).4,5 There are many published recommendations and guidelines for specific pain types; for example, the American College of Physicians has a practice guideline for low-back pain treatment.6 There are also guidelines for postoperative pain, fibromyalgia, rheumatoid arthritis, and acute pain in dentistry and dermatology, among many others.7 These help to implement best practices around individualizing pain plans and choosing the appropriate treatment, if needed.

Pain in Different Health Care Settings

Pain types can differ depending on the type of healthcare setting, and assessing and treating the pain in certain settings can come with its own set of challenges. There can be pain from the primary disease or injury, transient pain from various tools to monitor and diagnose, and pain from an actual procedure itself, such as surgery.8 In some cases, pain can require reassessment every few minutes or every few hours depending on the type and treatment.9

In chronic pain care settings, the patient may be intubated or temporarily incapacitated and the clinician won’t be able to assess or manage pain in the same way.10 Patients may also demonstrate delirium associated with long hospital stays, which might prevent proper assessment of pain and treatment.11 Pain associated with procedures in intensive care units (ICU) and other inpatient settings can include insertion/removal of tubes, catheters, and monitoring devices, repositioning, arterial puncture, incision, and many others.10 This type of pain may greatly affect the patient if they are hypersensitive and can aggravate existing pain.

Since pain is one of the top reasons people visit urgent care settings, emergency medicine physicians and other staff are usually adept in managing pain.12 However, due to factors, such as competing demands, lack of streamlined workflows, or limited care coordination, a full pain assessment and review of past opioid use or risk of OUD are often not carried out.13 In emergency departments (ED), non-opioids like acetaminophen and NSAIDs are commonly administered either alone or combined with opioids to treat some musculoskeletal pain and soft tissue injuries.14 However, opioids are not recommended as the first-line treatment in the ED, and there is data to show opioid use in the ED for chronic non-cancer pain carries greater risk than benefit.14

Primary care settings and office visits offer the chance for a clinician to thoroughly assess a patient’s pain using many methods mentioned previously. In the case of chronic pain, a multidisciplinary pain team can be greatly beneficial.15 This team can look like a primary care provider, specialist, psychologist, therapist, nurses, and other areas specific to the pain type.15

Before initiating opioid therapy in any setting, it’s important that the clinician has thoroughly assessed non-opioid and non-pharmacologic treatment options.16 Not all types of pain require opioids, but there are some types that rely mostly on the use of opioids. For example, opioids are considered frontline treatment for severe chronic cancer pain by palliative care specialists.17

Initiation, Titration, Rotation, and Discontinuation of Opioid Treatment

Before initiating opioid treatment, it’s crucial to check if the patient has any contraindications to opioid therapy (eg, respiratory disorder, mental health illness or prior substance use disorder (SUD), allergy to opioids, sensitivity to opioid side effects). Special attention should be given to concomitant medications and other substance use, such as benzodiazepines and central nervous system depressants, which can be life-threatening when taken with opioids.18 After this, the clinician can choose to begin with a trial dose of opioids, especially if the patient is opioid-naïve. A trial may also be chosen if the patient has a condition that may cause harm during opioid therapy (eg, sleep apnea, mild CPD/asthma), or if there is a mixed or complicated pain type.19 A clinician should consult a full list of contraindications and conditions where an opioid trial might be beneficial.

In cases where there is complex pain, severe or many comorbidities, a possible SUD or mental health illness, and/or other psychosocial or behavioral problems, the clinician should consult with other providers to possibly co-manage treatment or form a pain care team. This may also involve referring the patient to services outside the primary care setting.21 These services can include an advanced pain provider, SUD specialist, psychologist, neurologist, or therapist.21

Pain and risk assessment is significant prior to initiation of treatment and decides the treatment modality, but pain should be also reassessed during and after these key stages in treatment pathways: titration, switching (if needed), and tapering/discontinuation.

Titration of a treatment refers to the practice of slowly increasing the dosage, or increasing the time between dosages, in order to receive the optimal treatment response with minimal side effects.22,23 For opioids, titration is significant because many guidelines state that opioids should start with the lowest effective dose possible, regardless of the intensity of pain (especially if the patient is opioid-naive).24

An opioid may be switched or rotated to a different opioid or different route of administration if the patient is not responding well to the treatment or is experiencing many side effects.25 Switching can also occur due to drug interactions, financial reasons, change in the patient’s clinical status, or due to a personal preference.26 When rotating opioids, the clinician should start the new drug after assessing the new opioid’s potency and route of administration.26 The dose-equivalent should also be reduced to ensure safety, especially at higher doses.26 There are several dose reduction percentages and ratios available for reference online and in literature based on the pain type.26 There are also methods, such as slowly tapering off the old opioid while the new opioid is added in, titrating with the lowest dose possible.27 These and other methods should be determined on a case-by-case basis. The patient should be closely monitored when rotating opioids.26

Lastly, all opioid treatment plans should include a plan for tapering, or a slow decreasing of the dosage. This is challenging with long-term opioid use, as the patient may have developed a physical dependence.28 Opioids should never be abruptly discontinued, as this can cause extreme withdrawal symptoms, exacerbation of pain, and mental distress.28 The clinician should also factor in withdrawal symptoms when planning for tapering, and utilize a care team with resources for non-pharmacological and non-opioid therapy options in place.

Tapering or a slow discontinuation can be pursued by a clinician for a variety of reasons, including issues around misuse, addiction, overdose, side effects, change in the patient’s clinical status, another drug prescription, if the pain either has improved or has not changed at all, or if there has been prolonged opioid use.28 It is important the clinician communicates risks around discontinuation and tapering with the patient.28

References

  1. Wong SSC, et al. Analgesic effect of buprenorphine for chronic noncancer pain: A systematic review and meta-analysis of randomized controlled trials. Anesth Analg. 2023;137:59-71.
  2. Osmosis from Elsevier. Physiology of pain: Nursing. 2024. https://www.osmosis.org/learn/Physiology_of_pain:_Nursing
  3. Hunter CW, Falowski S. Neuromodulation in Treating Pelvic Pain. Curr Pain Headache Rep. 2021;25:9
  4. Gupta R, et al. Chronic headache: A review of interventional treatment strategies in headache management. Curr Pain Headache Rep. 2019;23:68.
  5. Levy N, et al. Post-surgical pain management: time for a paradigm shift. Br J Anaesth. 2019;123:e182-e186.
  6. Hauk L. Low back pain: American College of Physicians Practice Guideline on Noninvasive Treatments. Am Fam Physician. 2017;96:407-408.
  7. US Association for the Study of Pain. Journal of Pain’s Complete list of APS guidelines. https://www.jpain.org/content/apsguidelines
  8. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367:1618-1625.
  9. Dydyk AM, Grandhe S. Pain assessment. StatPearls. Last updated January 29, 2023. https://www.ncbi.nlm.nih.gov/books/NBK556098/
  10. Guo NN, Wang HL, Zhao MZ, et al. Management of procedural pain in the intensive care unit. World J Clin Cases. 2022;10:1473-1484.
  11. Devlin JW, Skrobik Y, Gelinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46:e825-e873.
  12. Venkat A, Fromm C, Isaacs E, Ibarra J, SAEM Ethics Committee. An ethical framework for the management of pain in the emergency department. Acad Emerg Med. 2013;20:716-723.
  13. Lowenstein M, et al. Impact of universal screening and automated clinical decision support for the treatment of opioid use disorder in emergency departments: A difference-in-differences analysis. Ann Emerg Med. 2023;82:131-144.
  14. Motov SM, et al. Pain management in the emergency department: A clinical review. Clin Exp Emerg Med. 2021;8:268-278.
  15. International Association for the Study of Pain (IASP). Multidisciplinary Pain Center Development Manual. Chapter 1: The Need for Multidisciplinary Pain Centers. September 2021. https://www.iasp-pain.org/resources/toolkits/pain-management-center/
  16. US Food and Drug Administration (FDA). FDA Updates Prescribing Information to Provide Additional Guidance for Safe Use. Last updated April 13, 2023. https://www.fda.gov/safety/medical-product-safety-information/all-opioid-pain-medicines-drug-safety-communication-fda-updates-prescribing-information-provide
  17. Pacheco S, et al. Adherence to opioid patient prescriber agreements at a safety net hospital. Cancers (Basel). 2023;15:2943.
  18. National Institute of Health (NIH). Benzodiazepines and opioids. Published May 17, 2024. https://nida.nih.gov/research-topics/opioids/benzodiazepines-opioids
  19. Department of Veteran Affairs. The Management of Opioid Therapy for Chronic Pain: Clinical Guidelines. May 2010. https://www.va.gov/painmanagement/docs/cpg_opioidtherapy_summary.pdf
  20. Hudson S, Wimsatt LA. How to monitor opioid use for your patients with chronic pain. Fam Pract Manag. 2014;21:6-11.
  21. Center for Substance Abuse Treatment. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series, No. 54. 2, Patient Assessment. 2012. https://www.ncbi.nlm.nih.gov/books/NBK92053/
  22. Hospital for Special Surgery (HSS). A Patient’s Guide to Opioid Tapering. Last updated June 26, 2023. https://www.hss.edu/conditions_patient-guide-opioid-tapering.asp
  23. Caffrey AR, Borrelli EP. The art and science of drug titration. Ther Adv Drug Saf. 2021;11:2042098620958910.
  24. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep. 2022;71:1–95.
  25. Treillet E, et al. Practical management of opioid rotation and equianalgesia. J Pain Res. 2018;11:2587-2601.
  26. Fine PG, Portenoy RK; Ad Hoc Expert Panel on Evidence Review and Guidelines for Opioid Rotation. Establishing “best practices” for opioid rotation: Conclusions of an expert panel. J Pain Symptom Manage. 2009;38:418-425.
  27. Webster LR, Fine PG. Overdose deaths demand a new paradigm for opioid rotation. Pain Med. 2012;13:571‑574.
  28. US Department of Health and Human Services (HHS). HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. Published October 2019. https://www.cms.gov/about-cms/story-page/cdcs-tapering-guidance.pdf

All URLs accessed August 15, 2024.

Defining Pain

Pain Assessment

Analgesia Modalities

Guidelines

Individualizing Pain Plans

Safe Opioid Use

Addiction Medicine

Reading and Resources

This activity is provided by Med Learning Group.

This activity is supported by an independent educational grant from the Opioid Analgesic REMS Program Companies.

Please see http://www.opioidanalgesicrems.com/Resources/Docs/List_of_RPC_Companies.pdf for a listing of REMS Program Companies. This activity is intended to be fully compliant with the Opioid Analgesic REMS education requirements issued by the U.S. Food and Drug Administration (FDA).

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