Treatment Options for Chronic Pain

Las Vegas—When treating patients with chronic pain, prescribers typically initiate opioid therapy. However, there are several other options that need to be considered to ensure that patients receive effective and safe care, according to health professionals who spoke at a satellite symposium at the AAPM meeting. They said that because of the potential for abuse, patients receiving opioids should be evaluated beforehand for any risk factors and monitored afterward to track their compliance. The session was titled Managing Patient’s Opioid Use: Balancing the Need and the Risk. Kathryn L. Hahn, PharmD, DAAPM, CPE, affiliate faculty, Oregon State University College of Pharmacy, and pharmacy manager, Bi-Mart Corp, Springfield, Oregon, said there are several barriers to effectively managing pain. For instance, a patient may be reluctant to admit to having pain or taking medications, may be fearful of becoming addicted to pain medication, may worry about side effects of the treatment, or may not receive adequate education about the treatments. In addition, a pain practitioner could be unknowledgable about treatment options, may not put a high priority on pain, or could fear patients getting addicted or the medications’ side effects. Furthermore, system barriers include inadequate or lack of reimbursement from insurers for pain therapies, restrictive regulations, and problems regarding the drugs’ availability. Before initiating opioid therapy, Dr. Hahn said prescribers should assess the patients’ risks for potential abuse. She suggested interviewing patients to determine their history with pain medication and whether they understand how to use pain medications as well as the responsibilities and consequences associated with the therapies. They should also conduct a physical examination and other appropriate tests, including assessing the risk for substance abuse, use, and addiction. According to Dr. Hahn, clinicians and patients may decide to implement a written chronic opioid therapy plan. That way, both parties understand their responsibilities and expectations in adhering to the medication. Kenneth L. Kirsh, PhD, director of behavioral medicine at the Pain Treatment Center of the Bluegrass in Lexington, Kentucky, then provided an overview of the Risk Evaluation and Mitigation Strategies (REMS) program, which was created in September 1997 by the Food and Drug Administration Amendments Act. The US Food and Drug Administration (FDA) can require REMS during any part of a product’s lifecycle. The REMS document that companies submit should include details on the product’s safety and reliability in providing benefits that outweigh potential risks. In April 2011, the FDA announced a REMS program for long-acting and extended-release opioids. Manufacturers are required to train prescribers about the risks of the opioids as well as provide information to prescribers that can be shared with patients about opioid use. “There will be requirements that affect everyone,” Dr. Kirsh said. “It’s becoming part of our daily functioning now.” According to Dr. Kirsh, there are several risk assessment tools that can be utilized to estimate the risk of a patient’s noncompliance and how closely patients should be monitored during their opioid regimen. He recommended a few options, including the Screener and Opioid Assessment for Patients with Pain, the Opioid Risk Tool, the Diagnosis, Intractability, Risk and Efficacy instrument, and the Screening Instrument for Substance Abuse Potential. Dr. Kirsh also mentioned other tools such as prescription monitoring programs, patient education, pill and patch counts, and urine drug screens. Lynn R. Webster, MD, cofounder and medical director at the Lifetree Clinical Research and Pain Clinic in Salt Lake City, Utah, followed with a discussion on how chronic pain can affect people on psychological, physical, and social levels. When deciding on treatment considerations, prescribers can choose pharmacologic or nonpharmacologic therapies and should assess patient characteristics and treatment duration. Pharmacologic treatments include opioids (short- or long-acting) and nonopioids such as antidepressants, anticonvulsants, and nonsteroidal anti-inflammatory drugs (NSAIDs). There are different levels of chronic pain treatments based on the disease severity. Mild options include acetaminophen and over-the-counter NSAIDs; moderate options include cyclooxygenase-2 inhibitors, tramadol, codeine, and opioid combinations; and severe options include single-entity opioids such as oxycodone and fentanyl. Although opioid misuse and abuse is a popular topic, Dr. Webster emphasized that genetic and environmental factors play a larger role than the medication’s molecules in determining the potential for misuse and abuse. “It’s not the molecules,” Dr. Webster said. “It’s the person and the environment.”