What is the next step in managing a 52-year-old woman with chronic pelvic pain syndrome who reports insufficient pain relief from opioids after a 10-day trial?

From the Guidelines

The next step in managing this 52-year-old woman with chronic pelvic pain syndrome who has had insufficient pain relief from opioids after a 10-day trial is to discontinue the opioid therapy and implement a multimodal approach. This approach is based on the most recent and highest quality evidence, which emphasizes the importance of a holistic, multimodal approach to managing chronic pain, as recommended by the CDC guideline for prescribing opioids for chronic pain 1. The guideline suggests that nonopioid therapy is preferred for treatment of chronic pain and that opioids should be used only when benefits for pain and function are expected to outweigh risks. Key components of this multimodal approach include:

• First-line non-opioid analgesics such as acetaminophen (500-1000mg every 6 hours, not exceeding 4g daily) and/or NSAIDs like ibuprofen (400-600mg three times daily with food) if not contraindicated
• Consider adding a low-dose tricyclic antidepressant such as amitriptyline (starting at 10-25mg at bedtime, gradually increasing to 50-75mg as tolerated) or a serotonin-norepinephrine reuptake inhibitor like duloxetine (30mg daily for one week, then increasing to 60mg daily)
• Pelvic floor physical therapy, which may include referral to physical therapy for pelvic floor strengthening exercises, as suggested by the survivorship: pain version 1.2014 guideline 1
• Patient education on the neurophysiology of pain, as recommended by the 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV 1 This multimodal approach is recommended because chronic pelvic pain often involves central sensitization and myofascial components that respond poorly to opioids, and opioids have limited efficacy for chronic pain conditions, carry significant risks including dependence, and may actually worsen pain through opioid-induced hyperalgesia with prolonged use 1.

From the FDA Drug Label

When a decision has been made to decrease the dose or discontinue therapy in an opioid-dependent patient taking Acetaminophen and Codeine Phosphate Tablets, there are a variety of factors that should be considered, including the total daily dose of opioid (including acetaminophen and codeine phosphate tablets) the patient has been taking, the duration of treatment, the type of pain being treated, and the physical and psychological attributes of the patient.

The next step is not directly addressed in the provided drug label. The label discusses tapering opioids in patients who are physically dependent, but it does not provide guidance on what to do when a patient reports insufficient pain relief after a 10-day trial. The FDA drug label does not answer the question.

From the Research

Next Steps in Managing Chronic Pelvic Pain Syndrome

The patient's report of insufficient pain relief from opioids after a 10-day trial necessitates a reevaluation of the treatment approach. Considering the complexities of chronic pelvic pain syndrome, the following options can be explored:

• Multimodal treatment approach: As suggested by 2, 3, 4, a multimodal treatment approach that incorporates pain education, self-care, behavioral therapy, physical therapy, and pharmacotherapy may be more effective in managing chronic pelvic pain syndrome.
• Interdisciplinary team involvement: Involving an interdisciplinary team of clinicians, as recommended by 2, 3, 4, can help address the biopsychosocial factors contributing to the patient's pain and improve treatment outcomes.
• Reassessment of treatment goals: Regular follow-up and reassessment of treatment goals, as suggested by 3, can help identify the need for adjustments to the treatment plan and ensure that the patient's needs are being met.
• Consideration of alternative treatments: Alternative treatments, such as cognitive-behavioral therapy, as suggested by 5, may be considered to address the psychological factors contributing to the patient's pain.
• Urine drug screen: While not directly related to the treatment of chronic pelvic pain syndrome, obtaining a urine drug screen, as mentioned in option E, may be necessary to rule out substance abuse or misuse, especially when prescribing opioids.

Treatment Options

The following treatment options can be considered:

• Combining opioids with other medications: Combining opioids with other medications, such as NSAIDs, as mentioned in option C, may be considered to enhance pain relief.
• Increasing opioid dose: Increasing the opioid dose, as mentioned in option B, may be considered, but this should be done with caution and close monitoring to avoid adverse effects.
• Discontinuing opioid treatment: Discontinuing opioid treatment, as mentioned in option A, may be considered if the patient is not experiencing adequate pain relief or is experiencing adverse effects.
• Adding a small dose of benzodiazepine: Adding a small dose of benzodiazepine, as mentioned in option D, may be considered, but this should be done with caution and close monitoring to avoid adverse effects, such as dependence or withdrawal symptoms.