Pain Clinic Guidelines

Introduction

For the past few decades, a conceptual shift has taken place regarding the treatment of chronic pain. Opioids have been encouraged for the treatment of all types of pain. In particular, chronic non-cancer pain was suggested as a treatable condition necessitating long-acting medications, without solid scientific evidence supporting that practice. As a society, we are reaping the consequences of that change in prescribing habits with an increase in opioid dependency, accidental drug overdoses, and heroin use. The expectation on the part of the public that there is a pill to be prescribed for any discomfort is harder to quantify but no less important.

The community consequences of excessive opioid prescribing are manifest. In addition to the mortality and quality-of-life consequences previously mentioned, we are facing an increase in communicable diseases associated with substance-use disorders (HIV, hepatitis, syphilis), strains on the court system and treatment programs, and a “lost generation” of patients dependent upon opioids who are a challenge to treat humanely and effectively.

The message embodied in this document is that opioids are powerful drugs that can create calm and relief when used wisely but can cause great harm when prescribed injudiciously. Every encounter with a patient in pain will require the same analysis, and patient safety should guide all treatment recommendations.

• What is the etiology of the pain, and would non-opioid treatment suffice?
• Are there risk factors present that would make the use of opioids unsafe for this patient?
• What is the usual expectation for pain for this condition? Is my patient’s response outside that expected range?
• Is there a medical justification for this dose of opioid, for this length of time, for this condition, in this patient?

Practicing outside those parameters puts your patient, your patient’s family, or the community at large, at risk. Too many pills prescribed for a given situation can create dependency in your patient, or if they are stolen or diverted, can feed the illicit habit of others.

This is an iatrogenic public health crisis, and all of us in the healthcare profession have to assume responsibility for fixing it.

To achieve genuine and lasting practice change, our entire community has to be educated concerning our current understanding of the appropriate management of pain. All of us need to understand the science that underlies current best-practice recommendations. Our patients and families need to hear the same message. We felt the best approach would be to promote a grassroots effort, achieving regional, broad support for these guidelines. Providers would share a common understanding, our patients would hear a consistent message, and the community at large would support these efforts.