Prescribing Practices: Pain Management

At the 2017 CDC Prevention for States Conference, Don Teater, MD, presented the following data:

• Between 1997-2007 there was a 600% increase in opioid prescribing.  Americans report more pain now than when we started prescribing.
• Prescriptions for acute pain lead to long-term use.  For a 1-day prescription, 6% of patients were still using the drug one year later.  For an 8-day prescription, 13.5% of patients were still using the drug one year later.  And for a 31-day prescription, 30% of patients were still using the drug one year later.
• In medical training, there is a lack of training about the treatment of pain and substance use disorder.  Most prescribers lack a thorough knowledge of the effects of opioids on the brain.
• Doctors overestimate the efficacy of opioids and underestimate the impact of safer alternatives.  Acetaminophen 500mg has a 62% efficacy in treating pain, however only 1% of prescribers think it is effective.  Fifty-five percent of prescribers thought that morphine 10mg was the most effective, even though research does not support this belief.

For patients who are already taking opioids, providers can use the following talking points with their patients:

• We know that long-term opioid use will decrease your functioning and increase your pain sensitivity.
• Opioids are not the only solution for chronic pain.
• For patients who take opioids longer than 45 days, one in ten people becomes addicted. 
• Given the huge potential for harm to you and your family, we want to explore other avenues for pain relief.
• We have to work together to explore different options for managing your pain.
• I am a part of your care team and want to see you often.

Patients play an active role in determining the best course of action to address chronic pain.  Effective pain management starts with:

• One doctor
• One pharmacy
• Determining how the pain started and how it is impacting current functioning and goals
• Reviewing past records and getting releases of information to communicate with all care team members
• Learning what other health conditions are impacting pain
• Including assessments such as mental health, chemical health, physical therapy, or occupational therapy assessments
• Willingness to try new approaches until finding something that is feasible and beneficial
• Developing a treatment plan that is reviewed frequently and has an emphasis on increasing functioning
• Routine follow-up and open communication

When setting functional goals related to pain, consider including one of each of the following:

• An active intervention such as exercise, yoga, physical therapy, walking, or swimming
• A passive intervention such as acupuncture, injections, or medication
• A mind-body intervention such as therapy, mindfulness, prayer or meditation

If opioids are a part of the pain management strategy, patients and doctors should discuss:

• The risks of dependence, withdrawal, addiction, and overdose
• The risks of diversion or sharing medications with family and friends
• How to properly dispose of unused medication
• How opioid use will be monitored (e.g. Utox, PMP, referral follow-up)
• Policies related to opioid prescribing
• The long-term plan to reduce/taper or eliminate the use of opioids

Often, non-opioid treatments for pain are not covered and/or covered differently than opioid treatments. 

Please visit the Resources tab for links to prescribing guidelines and clinical tools.

Don Teater, MD, presented at the 2017 CDC Prevention for States conference in Atlanta.

Please visit the Opioid Dashboard for more information on opioid overdose death, nonfatal overdose, use, misuse, substance use disorder, prescribing practices, supply, diversion, harm reduction, co-occurring conditions, and social determinants of health.