DEVELOPING A PATIENT PAIN PLAN
Discussing the benefits, risks and alternatives with your patient prior to the initial opioid prescription can be effective in establishing realistic expectations for pain management. In some cases, prescription pain relievers, including opioids, can be an important part of treatment, but alternatives should be discussed first.
Doctor and patient pain plan development tips:
- Determine if an opioid prescription is the right fit for your patient.
- Discuss pain treatment options, such as physical, occupational, and behavioral therapies that don’t include prescription drugs.
- Determine other prescribed medications that your patient may be taking.
- Determine the patient’s past or current drug and/or alcohol use.
- Convey possible risks and benefits of taking prescription opioids.
- Help the patient set realistic goals for managing their pain.
RELATIONSHIP WITH THE PATIENT
Opioids are often prescribed to treat severe pain from serious surgery or injury, or certain painful conditions, such as chronic back pain. While these medications can help relieve pain, they also carry serious risks, including addiction, accidental overdose, and even death. Creating a plan and setting goals with your patient could help prevent addiction and save their life. When prescribing an opioid, provide the patient with all pertinent information.
MANAGING DIFFICULT PATIENT CONVERSATIONS
Highly emotional conversations with a patient can be difficult to handle, but having steps to guide you through the discussion can make it easier.
Here are 5 steps to help guide you through a tough patient talk:
- Reduce opioid reliance: Be confident in presenting non-opioid interventions as the best chance for effective pain management.
- Value identification: Reflect on your core medical values. When you align with your values and believe that change is in the patient’s best interest, difficult conversations become manageable and rewarding.
- Set realistic expectations: Change doesn't happen overnight. If the patient leaves the office highly distressed it does not mean the office visit went poorly. It's just a natural part of the therapeutic process.
- Relationships as a resource: Use the trust and history you have built with your patient to help manage the conversation. When the provider and team can identify a patient’s triggers, conversations with that patient can be smoother.
- Get uncomfortable: Acknowledge with the patient that the conversation may be uncomfortable, but necessary because it’s in service of your values of safety and best practices in medicine.
PAIN MANAGEMENT GUIDANCE
In the event non-opioid therapies are exhausted and opioids are prescribed, start with the lowest dose possible and follow up to ensure pain management goals are being met, or if additional dosage is needed.
- Initiating and managing opioids prescribed for chronic pain.
- Opioid selection, dosage, duration, follow-up, and discontinuation.
- Assessing risk and addressing harms of opioid use.
The Centers for Disease Control (CDC) has provided refreshed guidance on opioid prescribing and has made an Opioid Guideline App available, which includes a Morphine Milligram Equivalent calculator and prescribing recommendations.
State-based Prescription Drug Monitoring Programs (PDMPs) are an important tool in managing the opioid epidemic since they may provide a comprehensive look into the prescriptions written for your patients. Each state has a unique website and rules associated with the PDMP. The PDMP Training and Technical Assistance Center (pdmpassist.org/) provides a state-by-state view.
BEHAVIORAL HEALTH AND OTHER SCREENING TOOLS
Screening for mental health and substance use disorders may be indicated prior to prescribing opioids. Screening may help to identify patients suffering from behavioral conditions and provide an indicator of the appropriateness of recommending cognitive behavioral therapy as a form of pain control. The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Human Resources Services Administration (HRSA) have compiled a list of screening tools that are effective in identifying behavioral conditions. The list is available at: integration.samhsa.gov/clinical-practice/screening-tools#drugs.
The most common screening tools include:
- Screening, Brief Intervention, Referral to Treatment (SBIRT) to identify potential substance use disorders.
- CAGE-AID questionnaire to identify potentially problematic use of drug and alcohol.
- Patient Health Questionnaire 9 (PHQ-9) to identify depression.
- Acute and Chronic Pain Flows. A variety of advisory groups, such as Oregon Pain Guidance, are issuing office-based flow charts to encourage local adoption.
Many resources exist to support providers and patients in the management of opioids. The following have been cited as helpful for providers: