Pain Management Practice Assessment

Practice Assessment

by Douglas L. Gourlay, MD, MSc, FRCPC, FASAM

& Howard A. Heit, MD, FACP, FASAM

Expert authors received compensation from Janssen Pharmaceuticals, Inc. for their contributions to PrescribeResponsibly.com

Pain and addiction can, and sometimes do, coexist.20 In the average family practice, the prevalence of a substance use disorder is at least that of the general population.38 One challenging question in assessing and managing risk in any medical practice is determining what proportion of the practice represents higher risk. For example, the prevalence of substance use disorders in the general population is 3 to 16 percent, with 10 percent being commonly reported in the pain management literature.20 In a primary care setting with a special focus on pain management, this number would be expected to increase. In practices limited to the assessment and management of individuals with concurrent pain and substance use disorders, the prevalence approaches 100 percent. Clearly, each practice will have differing needs with respect to risk assessment and management.

Knowing Your Practice

Knowing your limits in patient selection is a fundamental challenge in medicine in general, and in primary care in particular. Just as not all patients can be safely managed in the primary care setting, not all challenging cases need or necessarily can be transferred to specialty care. Of course, sometimes the risk posed by certain patients exceeds the experience and resources available to that primary care physician, and so the risk of these patients must be managed either through treatment of their concurrent substance use disorder, or by limiting the pharmacologic treatment options.28

Knowing Your Patients

In the treatment of chronic pain, it is important to establish reasonable therapeutic goals from the outset. It is rare that "pain free" or "to be cured" are reasonable goals for patients with chronic pain. Many patients have come to significant harm in a misplaced attempt to achieve a cure for their condition. While it is reasonable to expect to reduce pain scores and often improve function, there must be a constant balancing of risk and benefit in determining success or failure in any therapeutic trial. This is especially true with opioids.39

It is not uncommon for patients to share concern and, in some cases, fear about the use of a controlled substance. Although it is true that the majority of those who use prescription opioids for the treatment of pain do not become addicted,20 some fail to respond as expected, and a small number may engage in problematic behavior. In these cases, it is important to have a clearly defined "exit strategy" for discontinuation of the opioid class of drugs. Some patients may easily discontinue the use of opioids when it becomes apparent they are no longer serving a useful purpose, but most require a careful taper. Still others will require the assistance of those more experienced in withdrawal management.20

Physical dependence is neither necessary nor sufficient to define addiction.20 The fact that a patient may struggle to discontinue prescription medications, especially toward the end of the taper is no reflection on the presence or absence of a concurrent substance use disorder. A commonly recommended taper schedule is to reduce the medication by 10 percent every 1 to 2 weeks until the bottom 20 percent is reached, at which point the drop is reduced to 5 percent and the interval increased to every 2 to 4 weeks.20 This reflects the fact that for most patients, the more challenging point is the bottom of the taper. It is important to ensure that during the taper, medications of a similar class of drug are not inadvertently substituted for the drug being tapered. This is commonly seen in the patient who "successfully" stops drinking alcohol only to substitute his or her drug of choice through the chronic use of benzodiazepines.

In those cases when a patient expresses concern about addiction, it is important to have an open and nonjudgmental discussion. While the patient's initial concern may appear to be physical dependence and may require reassurance from the healthcare professional, it can be useful to probe more deeply. There may be more to the patient's concerns than originally stated. Aberrant behavior is an often late and unreliable sign of addiction. Addiction remains a diagnosis that is best made prospectively over time. On the other hand, pseudoaddiction is a diagnosis made retrospectively.20 Aberrant behavior that normalizes with more effective management of pain confirms this diagnosis.

Conclusion

By taking time to carefully assess the actual risk associated with your practice, you can optimize patient care while reducing the potential harm to you and others.

References Used in the Section:

  • 20 Gourlay, D. and H. Heit, Pain and Addiction: managing risk through comprehensive care. Journal of Addictive Diseases. 2008; 27(3):8.
  • 28 Chou R, Fanciullo GJ, Fine PG, et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. The Journal of Pain. 2009; 10(2):113-130.
  • 38 Rosenblum A, Herman J, Fong C, et al. Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. JAMA. 2003; 289(18):2370-2378.
  • 39 Fishman SM. Listening to Pain. Washington, DC: Waterford Life Sciences; 2006: 37-41.