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| A) | Patient preference | ||
| B) | Trials of opioid monotherapy only | ||
| C) | Diagnosis with an appropriate differential | ||
| D) | A single assessment of substance abuse risk |
All patients with pain have a level of risk that can only be roughly estimated initially and modified over time as more information is obtained. There are ten essential steps of opioid prescribing for chronic pain to help mitigate any potential problems [7]:
Diagnosis with an appropriate differential
Psychologic assessment, including risk of substance use disorders
Informed consent
Treatment agreement
Pre- and post-treatment assessments of pain level and function
Appropriate trial of opioid therapy with or without adjunctive medication
Reassessment of patient levels of pain and functioning
Regular assessment with the 5 A's (i.e., analgesia, activity, adverse effects, aberrant behaviors, and affect)
Periodically review pain diagnosis and comorbid conditions, including substance use disorders
Documentation
| A) | avoidance of all pain. | ||
| B) | avoidance of necessary medication use. | ||
| C) | reasonable improvements in pain, function, depression, and anxiety. | ||
| D) | Both B and C |
Opioid therapy should be presented as a trial for a pre-defined period (e.g., ≤30 days). As noted, the goals of treatment should be reasonable improvements in pain, function, depression, anxiety, and avoidance of unnecessary or excessive medication use [8]. The treatment plan should describe therapy selection, measures of progress, and other diagnostic evaluations, consultations, referrals, and therapies.
| A) | Analgesia | ||
| B) | Acceptance | ||
| C) | Affect (i.e., patient mood) | ||
| D) | Aberrant drug-related behaviors |
When implementing a chronic pain treatment plan that involves the use of opioids, the patient should be frequently reassessed for changes in pain origin, health, and function [8]. This can include input from family members and/or the state prescription drug monitoring program. Prescription drug monitoring programs are one of the most effective measures for reducing opioid analgesic diversion and abuse, but their efficacy is undermined by inconsistent use [9]. During the initiation phase and during any changes to the dosage or agent used, patient contact should be increased. Decisions regarding the continuation, modification, or termination of opioid therapy for pain should be based on evaluation of the patient's progress and the absence of substantial risks or adverse events [8]. At every visit, chronic opioid response may be monitored according to the 5 A's [11]:
Analgesia
Activities of daily living
Adverse effects
Aberrant drug-related behaviors
Affect (i.e., patient mood)
| A) | immediately halt an opioid if the side effects are unacceptable. | ||
| B) | never break or chew/crush tablets or cut or tear patches prior to use. | ||
| C) | share opioids with friends and relatives that cannot afford their own prescriptions. | ||
| D) | take other central nervous system depressants to manage opioid side effects. |
When prescribing opioids, clinicians should provide patients with the following information and instructions [10]:
Product-specific information
Taking the opioid as prescribed
Importance of dosing regimen adherence, managing missed doses, and prescriber contact if pain is not controlled
Warning and rationale to never break or chew/crush tablets or cut or tear patches prior to use
Warning and rationale to avoid other central nervous system depressants, such as sedative-hypnotics, anxiolytics, alcohol, or illicit drugs
Warning not to abruptly halt or reduce the opioid without physician oversight of safe tapering when discontinuing
The potential of serious side effects or death
Risk factors, signs, and symptoms of overdose and opioid-induced respiratory depression, gastrointestinal obstruction, and allergic reactions
The risks of falls, using heavy machinery, and driving
Warning and rationale to never share an opioid analgesic
Rationale for secure opioid storage
Warning to protect opioids from theft
Instructions for disposal of unneeded opioids, based on product-specific disposal information
| A) | They should be burned. | ||
| B) | They should be flushed down the toilet. | ||
| C) | They should be thrown in the garbage. | ||
| D) | There are no universal recommendations for the disposal of opioids. |
There are no universal recommendations for the proper disposal of unused opioids, and patients are rarely advised of what to do with unused or expired medications. According to the Office of National Drug Control Policy, most medications that are no longer necessary or have expired should be removed from their containers, mixed with undesirable substances (e.g., cat litter, used coffee grounds), and put into an impermeable, nondescript container (e.g., disposable container with a lid or a sealed bag) before throwing in the trash [12]. The FDA recommends that most opioid medications, including oxycodone/acetaminophen (Percocet), oxycodone (OxyContin tablets), and transdermal fentanyl (Duragesic Transdermal System), be flushed down the toilet instead of thrown in the trash [12]. Disposal by flushing down the toilet provides immediate and definitive elimination of safety hazards from intentional use or accidental exposure involving opioid products. All transdermal patch opioid products should be flushed down the toilet after folding in half by adhesive side against adhesive side [13]. The FDA provides a free toolkit of materials (e.g., social media images, fact sheets, posters) to raise awareness of the serious dangers of keeping unused opioid pain medicines in the home and with information about safe disposal of these medicines. The Remove the Risk Outreach toolkit is updated regularly and can be found at https://www.fda.gov/drugs/ensuring-safe-use-medicine/safe-opioid-disposal-remove-risk-outreach-toolkit [14]. Patients should be advised to flush prescription drugs down the toilet only if the label or accompanying patient information specifically instructs doing so.
| A) | inadequate analgesia. | ||
| B) | resolution of the pain syndrome. | ||
| C) | significant aberrant medication use. | ||
| D) | All of the above |
The decision to continue or end opioid prescribing should be based on a joint discussion of the anticipated benefits and risks. An opioid should be discontinued with resolution of the pain condition, intolerable side effects, inadequate analgesia, lack of improvement in quality of life despite dose titration, deteriorating function, or significant aberrant medication use [8].
| A) | Professionals tend to under-rate ethnic minority patients' levels of pain. | ||
| B) | Ethnic minority patients are less likely to have been given analgesics than white patients. | ||
| C) | Professionals are less likely to indicate ethnic minority patients' pain scores on their charts. | ||
| D) | All of the above |
In a meta-analysis of ethnicity and pain management researchers found that professionals under-rated ethnic minority patients' levels of pain and were less likely to indicate their pain scores on their charts compared with their white counterparts [28]. In addition, Black American and Hispanic patients were less likely to have been given analgesics than white patients.
| A) | Racism | ||
| B) | Fear of substance misuse | ||
| C) | The subjective nature of pain | ||
| D) | Lack of healthcare professionals' training regarding the intersection of pain and culture |
Societal and institutional barriers include racism, discrimination, poverty, lack of health insurance, and deleterious environmental factors in communities [35]. For example, groups that have historically (or currently) been victims of institutional racism and discrimination are more likely to delay seeking help for pain [28]. Some studies indicate that Black American men may experience higher levels of pain intensity in part due to their experiences with different forms of racial discrimination [20]. Even today, racial and ethnic minority patients are more likely to be placed in a negative valenced relationship [34]. In the context of pain management, healthcare providers are more likely to discount the pain due to the negative valenced relationship triggered by racism and discrimination [34].
| A) | Lack of culturally sensitive assessment for pain | ||
| B) | Patients' beliefs about appropriate pain management | ||
| C) | Expectations about racial and ethnic minority pain patients based on stereotypes | ||
| D) | Lack of training and knowledge about the intersection of pain and culture, race, and ethnicity |
Healthcare professional barriers may include professionals' beliefs about appropriate pain management; lack of training and knowledge about the intersection of pain and culture, race, and ethnicity; lack of culturally sensitive assessment for pain; and expectations about racial and ethnic minority pain patients based on stereotypes [38]. Consequently, practitioners may underestimate and minimize racial minority patients' pain experiences. In a qualitative study, Native American individuals described their complaints of pain being dismissed, receiving inadequate care, and neglected aftercare [39].
| A) | Yoga | ||
| B) | Vitamins | ||
| C) | Antidepressants | ||
| D) | Electromagnetic therapy |
Alternative remedies for pain can be classified into five different areas, and many can be used as adjuncts to conventional therapies [49,50]:
Alternative medications: Nonpharmacologic substances, such as those associated with homeopathic medicine, traditional Chinese medicine, and Ayurvedic medicine
Mind-body interventions: Interventions that focus on using the mind to influence bodily symptoms, including biofeedback, meditation, music therapy, and guided imagery. Mind-body interventions help reduce pain and improve other comorbid conditions, such as depression.
Biologically based interventions: Consumption of biologic products (e.g., herbs, vitamins, foods)
Manipulation strategies: Adjustment of focused areas of the body (e.g., chiropractic measures, massage, acupuncture)
Energy therapies: Balancing energy fields (e.g., electromagnetic therapy, reiki, qigong)