What is the evaluation process for chronic pain management?

From the Guidelines

Chronic pain evaluation should prioritize a comprehensive assessment, including a detailed medical history, physical examination, and diagnostic tests, followed by a multimodal approach incorporating non-pharmacological interventions like cognitive behavioral therapy (CBT) and physical therapy, as recommended by the 2017 HIVMA of IDSA clinical practice guideline 1. When evaluating chronic pain, it is essential to identify the location, intensity, duration, and quality of pain using validated tools like the Visual Analog Scale or Numeric Rating Scale.

Key Components of Chronic Pain Evaluation

• A comprehensive assessment that includes a detailed medical history, physical examination, and appropriate diagnostic tests
• Identification of the location, intensity, duration, and quality of pain using validated tools
• Consideration of non-pharmacological approaches, including physical therapy, CBT, and lifestyle modifications
• Medication management, starting with non-opioid analgesics and considering opioids only when other options fail

Non-Pharmacological Interventions

• Cognitive behavioral therapy (CBT) is recommended for chronic pain management 1, as it promotes patient acceptance of responsibility for change and the development of adaptive behaviors
• Physical and occupational therapy are also recommended for chronic pain management 1
• Yoga is recommended for the treatment of chronic neck/back pain, headache, rheumatoid arthritis, and general musculoskeletal pain 1

Medication Management

• Consider a stepwise approach, starting with non-opioid analgesics such as acetaminophen or NSAIDs
• For neuropathic pain, first-line agents include gabapentin or pregabalin
• Antidepressants such as duloxetine or amitriptyline may also be beneficial
• Opioids should be considered only when other options fail, starting with the lowest effective dose and regular monitoring, as recommended by the 2017 HIVMA of IDSA clinical practice guideline 1 Regular follow-up is essential to assess treatment efficacy, adjust interventions, and monitor for adverse effects, with a focus on routine monitoring of patients prescribed opioid analgesics 1 and the use of opioid patient–provider agreements 1 to ensure safe and effective pain management.

From the FDA Drug Label

When managing patients taking opioid analgesics, particularly those who have been treated for a long duration and/or with high doses for chronic pain, ensure that a multimodal approach to pain management, including mental health support (if needed), is in place prior to initiating an opioid analgesic taper A multimodal approach to pain management may optimize the treatment of chronic pain, as well as assist with the successful tapering of the opioid analgesic Initiate the dosing regimen for each patient individually, taking into account the patient's severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse Individually titrate morphine sulfate tablets to a dose that provides adequate analgesia and minimizes adverse reactions Continually reevaluate patients receiving morphine sulfate tablets to assess the maintenance of pain control and the relative incidence of adverse reactions, as well as monitoring for the development of addiction, abuse, or misuse

The evaluation of chronic pain should involve a multimodal approach to pain management, including mental health support if needed.

• Key considerations for managing chronic pain with opioid analgesics include:
  • Individualized dosing regimens based on the patient's severity of pain, response, and risk factors for addiction and abuse
  • Regular monitoring for adverse reactions, addiction, and misuse
  • Gradual tapering of the opioid dose to minimize withdrawal symptoms and optimize pain control 2, 2
• Good clinical practice dictates a patient-specific plan to manage chronic pain and taper opioid analgesics gradually.

From the Research

Chronic Pain Evaluation

• Chronic pain management is a major challenge for primary care providers, with many patients experiencing comorbidities such as mental health problems and opioid-related adverse events 3
• A multidisciplinary approach to chronic pain management has been shown to be effective in reducing patient-reported pain and improving outcomes 4, 5, 6
• Non-pharmacologic and non-opioid therapies, such as physical therapy, yoga, and acupuncture, are preferred by patients and can result in reduced pain scores 3
• Mindfulness meditation and cognitive behavioral therapy (CBT) have been found to reduce pain severity and sensitivity in opioid-treated chronic low back pain patients 7

Multidisciplinary Team Approach

• A multidisciplinary team approach, including advanced practice registered nurses (APRNs), physiatrists, physical therapists, pain psychologists, and other healthcare professionals, can provide comprehensive care for patients with chronic pain 3, 4, 6
• Collaborative ongoing communication among team members, the patient, and the case manager is key to program success 6
• Multidisciplinary programs can incorporate a biopsychosocial model to assess and treat pain, resulting in pain reduction, improved quality of life, and psychosocial functioning 4, 6

Treatment Outcomes

• Studies have shown significant declines in morphine equivalent daily dose (MEDD) and pain scores following multidisciplinary interventions 3
• Patients have reported improved functional improvement, fear of movement, and overall physical, psychological, and emotional well-being following multidisciplinary treatment 5
• Mindfulness meditation and CBT have been found to reduce pain severity and sensitivity, without adverse events 7