Pain Management
Chronic Pain
Differential
Common conditions: Headache/migraine, back pain, osteoarthritis, fibromyalgia
Consider: Neuropathic pain, malignancy, infection
Adjuvant treatment (information for patients)
Lifestyle modification: Hydration, nutrition, sleep hygiene, low-impact exercise, yoga, smoking cessation
Massage, physical therapy, occupational therapy
Cognitive behavior therapy
Complementary and alternative medicine (e.g. acupuncture)
Opioids
Safe prescribing
Opioids and organ failure
Fentanyl is most appropriate for patients with ESRD
Methadone should not be used in patients with liver failure
Opioids for chronic pain
Avoid in general and only start for pain refractory to all reasonable non-opioid analgesic strategies
Starting therapy: Continue all non-opioid analgesic therapies, set reasonable treatment goals, and sign pain contract
If possible, limit dosing to ≤ 50 oral morphine equivalents per day
Prescribe naloxone intranasal 4 mg PRN respiratory depression
See patient every month during the first year and perform urine drug screening at each visit
After 1 year, see patient every 3 months and perform random urine drug screening at 50% of visits (e.g. per coin-flip)
Example regimens
Tramadol 50 mg (OME conversion factor = 0.1): 50 mg q8h = 15 OME/day
Hydrocodone-acetaminophen 5-325 mg (Norco, Vicodin): 1 tablet q6h = 20 OME/day
Oxycodone-acetaminophen 5-325 mg (Percocet): 1 tablet q6h = 30 OME/day
Decreasing or discontinuing opioids
Reasons
Patient centered: No significant analgesia despite dose increases, lack of functional improvement, dependency or adverse effects impacting quality of life
Health risks (e.g. sleep apnea, chronic pulmonary disease, prolonged QT interval)
Dangerous co-prescribing (e.g. benzodiazepines, muscle relaxants, other sedatives)
Prescribing > 90 oral morphine equivalents per day
Tapering process
BRAVO framework: Broaching the subject, risk-benefit calculation, addiction, velocity and validation, other strategies
Decrease original dose by 10% every 2 weeks while maintaining original dosing schedule as long as possible
Advise patients that body pain will worsen with each dose decrease and then return to baseline
Add adjuvant pain control (see chart above) and nonpharmacologic methods (see above)
Withdrawal symptom treatment
Diarrhea: Loperamide 4 mg q6h PRN for diarrhea
Pain/myalgia: Naproxen 500 mg q12h, acetaminophen 650 mg q4h PRN
Depression/irritability: Trazodone 50 mg at bedtime, MDD 150 mg (may not improve insomnia)
Anxiety: Hydroxyzine 25 mg q8h PRN