Unfortunately, nonopioid analgesics are often disappointingly ineffective against neuropathic pain. Topically applied medications (e.g., capsaicin, lidocaine) may be useful in some cases, especially if allodynia (pain due to non-noxious stimuli) is present. Such adjuvants as antidepressant and/or anticonvulsant medications stabilize nerve functioning and are considered first-line treatments for this type of pain.14 The terms patients use to describe their neuropathic pain may direct the clinician toward the adjuvants that would be most effective. Unusual qualities of the discomfort or such descriptions as “burning” and “pins-and-needles” may signal a type of neuropathic pain that responds better to antidepressant adjuvants (e.g., nortriptyline, duloxetine); the stinging, electric, or shooting discomforts often associated with the altered structure and function of peripheral nerves tend to be more responsive to such anticonvulsant drugs as gabapentin or pregabalin.

While many assume that neuropathic forms of pain are opioid-resistant, opioids remain the class of drugs most likely to yield the desired therapeutic response.14 However, opioids alone are not always effective as monotherapy and may predispose some individuals to opioid-induced hyperalgesia, a condition in which a paradoxical reaction develops and pain actually increases when exposed to high-dose, long-duration therapy. Opioid use may be necessary but should be used cautiously and as part of a multimodal treatment plan that includes other opioid-sparing medications and nondrug therapies.


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Initiating opioids

Opioids are neither first-line pain relievers nor drugs of last resort, and they are not the most effective pain relievers for every patient. The decision to initiate opioid therapy for a chronic pain condition should not be entered into lightly, but it should not be avoided when medically necessary to reduce suffering, improve functioning, and enhance quality of life.

A serious concern of many HCPs is the possibility of being duped by patients who are feigning pain to get drugs to support a habit, criminal activity, or an addiction disorder. This concern, while justified, can be based on fears rather than facts, and many people who could benefit from opioids are being denied access to care unnecessarily. HCPs tend to overestimate the likelihood of drug-seeking motives when patients are actually demonstrating relief-seeking behavior.15-17 HCPs need to hone their skills in distinguishing therapeutic opioid responses from patterns of behaviors consistent with nonadherence, substance abuse/misuse, or a frank addiction disorder.

Whenever starting a person with chronic pain on opioid therapy, be sure the patient understands that these drugs may or may not help. If opioids are not effective or create more problems than improvements in physical and psychosocial health, a change in treatment plan is in order. This includes the possibility that opioids will be tapered and/or discontinued. As an alternative to abandoning these agents, HCPs can explore whether additional therapy is needed for other problems that are driving pain levels up. For example, approximately 40% of chronic-pain patients have a coexisting mental-health disorder, which, if not properly diagnosed or treated, may result in the individual self-medicating with opioids for symptomatic relief.18

To balance the concerns for safety, efficacy, and appropriate use, HCPs are urged to use Universal Precautions when starting a patient on long-term opioid therapy.15,16 The concept of universal precautions for pain medicine is borrowed from infectious disease, indicating that you can’t tell by looking at someone whether or not her or she has a serious undetected problem. Steps that are part of universal precautions include:16

  • Diagnostic workup with appropriate (physical/mental illness) differential diagnosis
  • Psychological assessment, including the risk of addictive disorders
  • Informed consent of the risks, benefits, and alternatives
  • Treatment agreement delineating the expectations of both parties
  • Assessment of pain and functioning
  • Trial of opioid therapy
  • Reassessment during opioid therapy
  • Periodic review of the primary disorder, comorbidities, and drug-use pattern
  • Documentation of each of these steps.

A comprehensive assessment should occur before therapy is intiated. Key areas to address include pain, functioning, medical diagnoses, and mental health disorders. This includes assessing for drug abuse and addictive disorders. Chronic pain often has none of the objective indications seen in its acute-pain counterpart, such as spikes in vital signs, facial grimacing, moaning, or writhing. Therefore, such subjective information as the patient’s reports of the nature, location, pattern, and intensity is considered the best indicator. The evaluation of the pain’s highest, lowest, and average intensity in the past month is often more telling of its severity than assessing intensity at the moment of examination. Rather than focusing on the perceived intensity of pain alone, many clinicians prefer to use the extent that pain interferes with functioning as an indicator of how the person is feeling and responding to therapy.

The astute clinician will look for such subtle behavioral signs of pain as clenched teeth; shallow irregular breathing; holding or rubbing the hurt body part; and stiff, slow, or asymmetrical movements. Other subtle signs include asymmetrical skin creases, muscle atrophy, antalgic gait, or wear-and-tear patterns on the person’s shoes. Gently palpate the painful area to identify abnormal temperature, muscle tone, or pain sensitivity. Exaggerated pain responses to the pinprick test (hyperalgesia), or such harmless stimuli as an alcohol swab (allodynia) are suggestive of neuropathic pain. Persistent pain can also affect memory and concentration, and patients may easily become angry, frustrated, or depressed.

Many HCPs find assessing the risk of drug abuse/addictive disorders to be difficult. Easy-to-use screening tools are readily available in the literature and on the Web (Table 1). The Screener and Opioid Assessment for Patients with Pain (SOAPP) or Opioid Risk Tool (ORT) are examples of instruments that can be used to identify inidviduals who may be at higher risk for developing problematic behaviors before you start them on opioids.

When dealing with a patient who has a suspected or documented history of substance abuse, consider using the Current Opioid Misuse Measure (COMM) or Drug Use Questionnaire (DAST-20), which are designed to identify persons with current drug problems.9

 

Ask direct questions about drug use in a respectful, nonjudgmental manner. Tell the patient that honest disclosure of all drug use will lead to improvement—not denial—of care. Objective signs include an intoxicated appearance, track marks on the skin, and erosions of the nasal septum. Signs associated with opioid use or withdrawal may not signal a problem for a patient who has been prescribed opioids, but would be cause for concern if seen in a patient who denies taking opioids.

Changes in personality, social habits, or role functioning can also be signs of an addiction disorder, but these can be subtle and are likely to be most obvious to persons closest to the patient. Whenever feasible, speak with a significant other about observed drug-use patterns and changes in functioning.

Assessments focusing on drug use and related risk factors are not intended to determine who qualifies for an opioid trial. Instead, these evaluations define who may need prescriptions with fewer pills dispensed, more frequent follow-up, or referral to an appropriate specialist as the treatment plan is established. If your patient is at high risk for or believed to have an active addiction disorder, seek input from a specialist before prescribing opioids unless such input would substantially delay the initiation of effective treatment.

Protracted delays should be avoided because high levels of pain can increase stress and drug craving, which can trigger illicit use or exacerbate an addiction disorder.16 Similarly, patients transferred to your care who are opioid-dependent because they have received legitimate prescriptions should continue to get opioids while decisions are made about the appropriateness of ongoing therapy to prevent triggering withdrawal-mediated pain. A history of drug abuse, dependence, or addiction should not disqualify a person from receiving opioids when necessary for pain.

Although mentioned as part of the universal precautions, opioid-treatment agreements, consent forms, and urine drug toxicology (UDT) screens are controversial. Many settings have adopted these practices for all patients, but the cost-benefit ratio has been called into question, especially for UDT screens. This test can identify drugs that should and should not be in the patient’s system, but it is very expensive, has imperfect accuracy, and its results can be misinterpreted. The UDT screen can objectively monitor adherence and detect substance abuse that can support the evaluation and clinical judgment. Given cost-benefit concerns, it may be prudent to perform UDT screening before prescribing opioids and annually thereafter. A more frequent screening schedule may be appropriate for those patients deemed to be at higher risk, and the clinician might consider using opioids designed to be tamper-resistant or abuse-deterrent.

The use of treatment agreements and consent forms is less controversial and can standardize the education process and establish realistic expectations as to the medication’s potential benefits and limitations. Patients can be informed of their obligation to secure their medication supply using one prescriber/pharmacy and to not distribute these controlled prescription drugs to other persons. Key principles to be explained include safe use, locking medications, and proper disposal of unused prescription medications.19,20 Issues related to safe use of long-term opioids include the avoidance of skipping doses or suddenly stopping therapy, taking unauthorized doses, and operating heavy machinery while on medication. The agreement can also convey specific advice regarding driving and traveling with prescription opioids. This document can also delineate what distinguishes a successful trial from one that has failed and necessitates tapering or discontinuing the opioid while continuing to treat pain with nonopioid strategies.