Chronic pain can be one of the more challenging conditions to manage, especially when it has been refractory to multiple modalities. An appreciation of chronic pain and its prevalence, along with thorough understanding of provider responsibilities, patient rights and the appropriateness of opioid analgesics for this population, are needed. Such knowledge provides a foundation for evaluating chronic pain and developing an individualized management plan. When opioids are used, prepare for both expected and unexpected results.
Chronic pain is pain without apparent biologic value that has persisted beyond the time in which normal healing should have occurred, usually 3 months.1 In 2004, chronic pain was internationally recognized as a major health care problem and a disease in its own right.2 Today, countless medical experts and health agencies contend that chronic pain should be treated with the same priority as the disease that caused it.3
History of Standards
The creation and endorsement of formal guidelines for the use of opioid analgesics in chronic pain management is relatively new. The American Pain Society (APS) and the American Academy of Pain Medicine (AAPM) issued a statement in 1996 to define when and how opioids should be prescribed for patients with chronic pain.4
Despite this formal position, pain continued to be undertreated due to fears of legal and criminal liability for prescribing controlled substances.5,6 This prompted the development and 1998 adoption of the Model Guidelines for the Use of Controlled Substances by the Federation of State Medical Boards of the United States.7 This document, which became policy in 2004, defines when opioids are appropriate for acute and chronic pain and details patient monitoring to deter drug diversion.8,9
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has issued standards on pain assessment and management. The standards, which took effect in 2001, state that all patients have the right to appropriate assessment and management of pain; that all patients should be assessed for pain and receive individualized care; that response to treatment should be monitored; and that treatment plans should be modified when necessary.10
Although the JCAHO standards provided a formal framework for pain management, they did not stipulate how appropriate management would be achieved, and a number of guidelines were subsequently issued.9-12 The prevalence of guidelines and JCAHO standards today means that failing to prescribe appropriate medications constitutes undertreatment of pain and a departure from acceptable standards of practice.8
An analysis of international studies shows that 1 in 5 adults and 1 in 3 older adults experience moderate to severe pain lasting more than 3 to 6 months.1,13 A study of more than 3,500 primary care patients in the United Kingdom found that about half reported pain lasting more than 3 months.14
And an international study that included the United States revealed that about 20% of more than 5,000 primary care patients experienced pain for more than 6 months.15 Put in everyday terms, as little as 1 in 10 and as many as 1 in 2 patients who present to a health care provider may have chronic pain.
Trends in Prescribing
Arthritis and other musculoskeletal disorders are the most frequently mentioned chronic health conditions significant enough to result in activity limitations among U.S. adults ages 18 to 64.16
An analysis of office visits and opioids prescribed for patients with musculoskeletal disorders in 1980 and 2000 revealed that office visits did not increase for these conditions. This analysis, which was based on data from the National Ambulatory Medical Care survey, also revealed that prescriptions for opioid analgesics for chronic pain doubled (8% to 16%), and the use of stronger opioid analgesics quadrupled (2% to 9%).17
The increase in opioid analgesic prescriptions is a sign that progress has been made in pain management.18-21 However, this trend has not allayed concerns that increased use of opioids would lead to more opioid abuse and addiction. As a result, studies were conducted to identify any abuse of opioid analgesics.
Opioid Use and Abuse
Three studies used two sources of data to analyze medical use and abuse of opioid analgesics from 1990 to 2002. These datasets included the Drug Enforcement Administration's Automation of Reports and Consolidated Orders System (ARCOS) and the Substance Abuse and Mental Health Services Administration's Drug Abuse Warning Network (DAWN) for medical use and abuse.
The first study analyzed use and abuse of fentanyl, hydromorphone, oxycodone, morphine and meperidine from 1990 to 1996. Increased medical use did not appear to contribute to opioid analgesic abuse.19 The second study examined the use of fentanyl, morphine and oxycodone from 1997 to 2001 and documented similar results: Abuse was low despite increased medical use.20 The last study analyzed fentanyl, hydromorphone, oxycodone, morphine and meperidine use from 1997 to 2002.21 Increased medical use was associated with increased abuse but remained a small part of total DAWN mentions.
The increased use and greater availability of opioid analgesics for legitimate medical purposes further indicate progress in pain management.18-21 Increased opioid abuse, albeit a relatively small part of total abuse as defined in the three studies, emphasizes the need for continued vigilance to minimize nonmedical use.19-21
Evaluating for Opioid Use
Addressing a patient's right to pain management and developing an appropriate treatment plan begin with a thorough evaluation of the patient and his or her pain complaint. This can be accomplished by focusing on four objectives:
Determine whether an appropriate workup has been completed and whether additional studies are warranted. Rule out an occult cause for pain, and identify any other etiologies.
Establish whether opioid analgesic use is indicated. Inadequate response to all appropriate nonopioid analgesics and nonpharmacologic interventions constitutes an indication.5,11,22,23 In addition, pathology must support the patient's pain complaints. For opioids to produce analgesia through actions at opioid receptors and to modulate ascending and descending pathways, an identifiable pathology must exist.23-25 In the absence of pathology or noncorresponding pathology, exposure to and use of opioids can result in a continuum of behaviors ranging from change in affect to addiction.5,26,27 These events can also occur in the presence of corresponding pathology, with one distinct difference: A medical indication for opioid use existed.
Identify patients at risk for adverse consequences such as misuse or abuse of opioids. Pertinent positives will differentiate patients at risk (e.g., a remote history of alcohol abuse) or at higher risk and in whom opioid use is relatively or absolutely contraindicated (Table 1)9,23,28,29
Provide a baseline to compare effectiveness and adverse consequences related to planned interventions.